When you go to a doctor’s office, hospital, or medical facility, you assume the people providing your care are legitimate, qualified professionals. Nevertheless, there have been alarming cases of individuals posing as physicians or nurses to unlawfully treat patients. This fraudulent behavior puts lives at risk from improper care and data mishandling.
To protect patient safety, the U.S. healthcare system relies on a range of safeguards and verification processes to validate the identities and credentials of medical providers.
Unique Provider Identification
The foundation for provider validation is the National Provider Identifier (NPI) – a unique 10-digit number issued to every licensed healthcare professional in America. Think of it like a national medical “ID number”.
To receive an NPI, providers must be appropriately licensed and credentialed by the state where they practice. Their NPI application undergoes rigorous screening by the National Plan and Provider Enumeration System (NPPES) registry to verify their qualifications.
Once approved, this unique NPI number is required for all administrative transactions; things like billing, ordering prescriptions or tests, and referring patients. Essentially, you can’t operate as a provider without an NPI linked to your identity.
Routine NPI Lookups
So how does the NPI system protect patients? According to the folk at Find-A-Code.com, any healthcare facility employing or contracting with providers is required to perform routine NPI lookups and primary source verifications to confirm:
- The provider’s NPI matches their credentials on record.
- Their licenses/registrations are currently active and unencumbered.
- They maintain proper education, training, and malpractice coverage.
- Their specialties and services are represented accurately.
Only after successfully verifying a provider’s identity and qualifications through the NPI records can an organization grant them credentials to practice and access data systems. This process gets repeated every few years as part of an ongoing vetting cycle.
If an individual’s records reveal disciplinary actions, suspended licenses, or other concerning issues during an NPI lookup, the provider credentials will be revoked or restricted accordingly. This prevents potentially unsafe individuals from circumventing normal employment screenings.
Importance of Primary Sources
A critical part of the NPI lookup is cross-checking databases directly from credential-issuing authorities, like state medical boards and specialty certification agencies. Verifying primary source data is crucial because licenses and credentials can expire or be revoked.
Anytime there is a gap between a provider’s claimed credentials and what the authoritative sources show, that raises an immediate red flag. It could indicate fraud through the use of falsified documentation.
Organizational Safeguards
Beyond the NPI lookup system, healthcare facilities maintain additional screening protocols to validate staff identities and backgrounds, including:
- Primary source credentialing with education, training, and employment verifications.
- Systematic license monitoring across all issued credentials.
- Comprehensive background checks for criminal history and disciplinary actions.
- Review of government exclusion lists like Medicare/Medicaid fraud databases.
- Identity proofing with photo ID, fingerprints, drug testing, etc.
These extensive onboarding, monitoring, and access management controls create a cohesive system for validating healthcare providers as 100% legitimate prior to delivering any patient care or managing sensitive data.
While no system is perfect, the combination of unique NPI identifiers, primary source verifications, and organizational competency checks makes the U.S. healthcare system one of the most stringent in the world at verifying provider identities.
Conclusion
Requiring providers to be fully vetted and credentialed through standardized processes brings much-needed transparency and accountability to the complex U.S. healthcare landscape. Patients can have greater confidence knowing there are robust systems in place to validate the individuals responsible for their care.
As cyberattacks and medical identity fraud sadly become more prevalent, strong provider validation controls will only grow more important for maintaining safety and privacy across the industry. Getting it right is a matter of life and death.
