1. Credentialing, Accreditation, and Certification: What the Radiologist Needs to Know

2. A Special Thank You to: Dr. David M. Yousem, M. D. , M. B. A
A Special Thank You to: Dr. David M. Yousem, M.D., M.B.A.
Professor, Department of Radiology
Vice Chairman of Program Development
Director of Neuroradiology
Johns Hopkins Hospital for allowing the use of his material/content in this presentation Dr. Yousem’s online lecture series can be viewed at: Dr. Yousem’s project was funded through an RSNA Educational Grant

3. In this presentation we will discuss:
What is Credentialing? Who provides it and why is it needed?
What is Accreditation? What is it important?
What is Certification and Maintenance of Certification? How and when is it obtained?

4. What is Credentialing?
Credentialing is a systematic review process used by a hospital or managed care organization (MCO) to assess and confirm that a physician is competent and qualified to practice medicine in their designated field
The landmark Darling v.Charleston Hospital case in the 1960’s established that hospitals had an obligation to verify the competency of the physicians who practice within its walls, and thus credentialing was born

5. Credentialing Committee
Each hospital or MCO will have their own credentialing committee
The committee is composed of various health care workers: doctors, nurses, physician assistants, administrators, etc. Having a radiologist on the committee is ideal since the committee determines the criteria necessary to grant specific privileges to individual physicians
The committee also collects, reviews, and verifies various documents to ensure that a physician meets 6 core competencies: medical knowledge, technical skills, clinical judgment, interpersonal skills, communication skills, and professionalism.

6. Credentialing Support Databases
Committees can use various credentialing support services to verify physician information:
National Practitioner Data Bank:
Provides information regarding malpractice claims, restrictions of privileges, professional society adverse sanctions, licensure actions by state boards, DEA reports, and CMS exclusion actions. Check your status at
Healthcare integrity and Protection databank:
Discloses any fraudulent Medicare or Medicaid claims American
Board of Medical Specialties:
DEA, CDS, Centers for Medicare and Medicaid Services (CMS)

7. Delay or Denial of Credentialing
There are particular RED FLAGS that can delay or deny credentialing:
Personal conduct history - Poor references
Deferred letters - Alcohol or substance abuse
Multiple malpractice suites - Short employment periods
Unexplained gaps in employment or education
If there is a high risk that credentialing will be denied, it is in the best interest of the physician to resign before the committee investigates or makes their conclusion, as this denial of credentialing will remain on the physician’s permanent record

8. Delineation of Privileges
The Credentialing committee also determines each physicians privileges depending on their specific training and skill level
For example, the committee can specify the minimum number of CT, MR, US, myelograms, biopsies, etc that must be read or performed in a specific amount of time to obtain/maintain specific privileges
Again, it is important for a radiologist to be on the committee to help determine these criteria
These criteria ensure physicians, both radiologist and non-radiologist, are competent in their areas of care

9. Recredentialing
Once credentialed by a hospital, a physician must apply for recredentialing every 2 years to maintain their privileges

10. Why is Credentialing Important?
A physician MUST be credentialed by a hospital to work there
Part of credentialing is delineation of privileges for every hospital staff member, ensuring a physician’s competence in their particular skill set

11. What is Accreditation?
Accreditation of a health care facility ensures that it is maintaining a high standard for the quality and safety of health care delivery
The Joint Commission (formerly the Joint Commission Accreditation of Healthcare Organizations - JACHO) or the American Osteopathic Association (AOA) has the ability to accredit hospitals
Periodic inspections and reviews
The National committee for Quality assurance (NCQA) is a nongovernment agency that accredits MCO, PPOs, health plans, etc
The American College of Radiology (ACR) accredits imaging facilities

12. ACR Accreditation of Imaging Facilities
ACR sets protocols and guidelines for imaging facilities to ensure image quality, equipment, and reporting meet the highest standards in quality and safety
ACR evaluates the imaging equipment and the physician in a practice setting
This includes radiologists and non-radiologist imagers such as cardiologists, orthopedists, chiropractors, or any physician using imaging equipment in their practice

13. ACR Accreditation Factors evaluated by the ACR: Image quality
Film storage and handling
Patient identification
Right and Left marker placement
Written reports
Frequency of equipment inspection

14. Why is ACR Accreditation Important?
It not only ensures the quality of imaging and reporting but is also REQUIRED by some insurers to be reimbursed
Accreditation also restricts non-radiologist from obtaining inadequate images or from obtaining images but not providing written reports
More information regarding ACR accreditation can be found on their website,

15. What is Certification?
Certification is a lifelong process by which the ABR and/or ABMS ensures that you, as a radiologist are adequately qualified and are involved in continued learning and improvement
There are two certification processes, both of which are awarded by the ABR:
Initial certification
Maintenance of Certification (MOC)

16. To Apply for Initial Certification you must have:
5 years of approved training
1 year clinical
4 years in Diagnostic Radiology, which includes 4 months of Nuclear Medicine, 3 months of Mammography, and no more than 12 months in any one discipline
Passed all ABR examinations
Currently: Physics, Written, and Oral Examinations
For the 2012 class and forward: a Core examination during R3-R4 year and Certifying examination 15 months after R4 year
Cardiac life support certification, high moral and ethical standards, and proof of valid state licensure or Canadian equivalent

17. Certification and Recertification
You have a 10 year period after completing training in which to obtain initial certification, which is valid for 10 years
You must then apply for Recertification through the ABR and/or American board of medical specialties (ABMS) to continue practicing as a radiologist

18. MOC: Recertification
To become recertified, you must practice radiology, maintain an active unrestricted license and professional standing, pass the Maintenance of certification (MOC) exam, and meet the following specific requirements over a 10 year period:
250 CME credits SAM
MOC exam PQI projects

19. Specific Recertification Requirements: A Closer Look
250 category 1 CME credits
70% in a subspecialty or area of practice, 30% general
20 SAM (self assessment modules, each is 90 min)
4 SAM must be in general knowledge, 16 in clinical content
At least 6 need to be subspecialty specific
May overlap with the CME requirement
SAM can be found on the ACR or subspecialty websites
MOC examination
Comprehensive 4 hr knowledge based computer test
80% clinical content, 20% non-interpretive skills including safety, life support, ethics, physics

20. Specific Recertification Requirements: A Closer Look
3 PQI (Practice Quality Improvement) projects in 10 years
PQI project is a means of self-evaluation and continued quality improvement
The project must be in one of these five areas: patient safety, accuracy of interpretation, report timeliness and critical value reporting, referring physician services, practice guidelines.
PQI projects can be designed by an individual radiologists, radiology practice groups or departments, institutions, healthcare systems, or by professional radiology societies
Every radiologist participating may receive PQI credit for the project
More PQI information can be found at

21. Summary
Credentialing is hospital based process which ensures physician competence and delineates physician privileges
Accreditation of a facility by the ACR assures imaging quality standards and is required for insurance reimbursement
Certification and MOC by the ABR ensures that radiologists are involved in continuous learning and self-improvement

22. References