Credentialing is the contractual and regulatory foundation of every healthcare staffing arrangement. When it fails — when a placed clinician has an unverified license restriction, an undetected exclusion record, or an undisclosed adverse action — the consequences are borne not just by the agency but by the facility that granted clinical access. These questions should be answered in writing, incorporated into your Master Service Agreement, and treated as non-negotiable requirements — not aspirational standards.
The Regulatory Context for These Questions
The credentialing obligations in healthcare staffing derive from multiple overlapping regulatory frameworks. The Joint Commission's Staffing Standards (HR.01.02.05, HR.01.04.01) require that facilities using agency or contract staff verify credentials and competencies through a process equivalent to what they use for employed staff. CMS Conditions of Participation for hospitals (42 C.F.R. § 482.12(b)) and nursing facilities (42 C.F.R. § 483.35) require that staffing agency clinicians meet the same standards as direct employees. State licensing boards — Texas Board of Nursing, Texas Medical Board, Texas PT & OT Board, and others — impose primary-source verification requirements as a condition of facility licensure.
Understanding this framework clarifies why these questions are not administrative formalities: they are the documented evidence base for your facility's regulatory compliance posture. If a survey or audit identifies a credentialing deficiency related to an agency clinician, the absence of documented verification by the agency — or the facility's failure to confirm that verification occurred — creates direct liability.
The 12 Questions Every Administrator Should Have Answered in Writing
1. Are all placed clinicians W-2 employees or 1099 independent contractors?
This is the foundational question and must be asked explicitly. W-2 employees are covered by the agency's workers' compensation and professional liability insurance policies. Independent contractors are not — and under Texas law, a facility that receives services from an uninsured 1099 contractor injured on its premises may bear workers' compensation liability directly. Additionally, misclassification of employees as independent contractors under IRS guidelines creates employment tax liability for both the contractor and, potentially, for entities that facilitated the arrangement. The IRS, DOL, and EEOC have all increased enforcement focus on worker classification in healthcare staffing since 2023.
2. Do you perform primary source verification — not document review — for every license?
Primary source verification means checking directly with the issuing licensing authority: the Texas Board of Nursing (bon.texas.gov) for RNs and LVNs, the Texas Medical Board (tmb.state.tx.us) for PAs, the Texas PT & OT Board (ptot.texas.gov) for therapy professionals, the ARRT (arrt.org) for imaging technologists, and so on. Reviewing a copy of the clinician's license card — digital or physical — is not primary source verification. The National Committee for Quality Assurance (NCQA) Credentialing Standards, which form the basis for most hospital and health plan credentialing requirements, define primary source verification specifically as direct confirmation from the original source.
Ask the agency to show you an example of a primary source verification printout with timestamp. A compliant agency will produce one within minutes.
3. How often do you screen active clinicians against OIG LEIE, SAM.gov, and the Texas HHS OIG exclusion list?
The answer must be monthly — and the agency must be able to produce documentation demonstrating their monthly screening logs. Pre-hire screening alone does not meet the OIG's program guidance or most healthcare compliance program standards. An individual can be added to the exclusion list at any time following hire, and the facility bears liability for services rendered by an excluded clinician during any period of undetected exclusion, regardless of whether the agency was responsible for monitoring. (42 U.S.C. § 1320a-7a; OIG Special Advisory Bulletin on the Effect of Exclusion, 2013.)
4. Do you conduct NPDB queries for Advanced Practice Providers and hospital-based RNs?
The National Practitioner Data Bank (npdb.hrsa.gov) contains reports of medical malpractice payments, adverse licensure actions, clinical privilege restrictions, and exclusions from Medicare and Medicaid. For APPs (NPs, PAs, CRNAs, CNSs) and RNs seeking hospital privileges, NPDB queries are required under 45 C.F.R. § 60.10. A nurse practitioner with a clear Texas BON license may nonetheless have a significant NPDB report reflecting a malpractice settlement or adverse hospital privilege action in another state — information that does not appear in any license verification search.
5. What workers' compensation coverage structure do you maintain?
Confirm the name of the carrier, policy limits, and whether coverage is obtained through the Texas Department of Insurance regulated system or as a certified self-insurer under the Texas Labor Code. Note that Texas is the only state in which workers' compensation coverage is not legally mandated for employers — making it possible (though inadvisable) for an agency to operate without it. A certificate of insurance should be available upon request and should name the carrier and policy period. Workers' compensation coverage is the mechanism that protects both the clinician and the facility from liability when a clinician is injured on the job.
6. What professional liability (E&O) insurance do you carry, and does it cover the clinician's clinical actions at my facility?
Minimum acceptable professional liability coverage for a healthcare staffing agency is $1,000,000 per claim / $3,000,000 aggregate. Critically, confirm whether this coverage applies to the clinician's professional liability while working at your facility or only to the agency's staffing operations (recruiting, credentialing, placement). Some agency professional liability policies cover only agency errors — not clinical errors made by placed clinicians — in which case the facility's own professional liability policy becomes the primary coverage for clinical incidents.
7. What are your drug screening requirements — and do you use MRO review?
A 10-panel pre-employment drug screen collected at a SAMHSA-certified collection site, reviewed by a Medical Review Officer (MRO) before results are reported, is the industry standard. Instant point-of-care tests without MRO review do not meet SAMHSA guidelines, generate higher false-positive rates, and do not provide the evidentiary foundation needed if a result is challenged by the clinician. Confirm that the agency uses only SAMHSA-certified collection sites and that all results are MRO-reviewed before clearance is granted.
8. For APPs — who is responsible for physician supervision and collaboration agreements?
This question is the one most often overlooked in the contracting process, and the most consequential when missed. Texas Medical Board rules (21 Tex. Admin. Code § 185 et seq. for PAs; Texas BON rules for NPs) require that Nurse Practitioners and Physician Assistants practicing in clinical settings have appropriate supervising or collaborating physician agreements in place. This agreement must be executed at the facility level between the APP and a supervising/collaborating physician credentialed at that facility. The agency cannot execute this agreement on behalf of the facility. The facility must have this in place before any APP begins practicing. A competent agency will raise this requirement proactively and will not schedule an APP to a facility that does not have the arrangement confirmed — but the responsibility remains with the facility.
9. What is your process when a clinician tests positive on a drug screen or appears on an exclusion list?
The agency should be able to describe a specific, documented process: immediate removal from all assignments, written notification to affected facilities within a defined timeframe (24 hours is the standard), documentation of the discovery retained in the clinician file, and reporting to applicable licensing authorities if legally required. Vague answers ("we handle it immediately") are insufficient. The process should exist in written policy that the agency is willing to share.
10. What immunization verification do you require, and how do you handle declinations?
Minimum required immunizations for clinical placements include: Hepatitis B (three-dose series or positive titer), MMR (two-dose or positive titer), Varicella (two-dose or positive titer or documented disease history), current-season influenza, and TB screening (two-step PPD or QuantiFERON within 12 months). Some facilities also require COVID-19 vaccination documentation, Tdap (for pediatric and L&D placements), and annual physical clearance. The agency should accommodate facility-specific requirements for additional immunizations and should maintain signed declination forms for any required vaccines refused by the clinician. Note that some facilities do not accept influenza declinations — this must be disclosed in the staffing agreement.
11. Can you accommodate facility-specific competency requirements beyond your standard checklist?
Your facility may require NIH Stroke Scale certification for stroke unit nurses, TNCC for trauma nurses, NRP for NICU or L&D nurses, or specific EHR training before system access is granted. Ask whether the agency can verify and document these additional requirements — and what the lead time is for placing a clinician who needs to obtain a certification your standard pool may not have. The answer shapes how much advance time you need to provide when placing specialty orders.
12. Can I review your credential checklist and a sample completed clinician file?
Transparency is the most basic test of a credentialing-compliant agency. A well-run agency should be willing to share its pre-placement credential verification checklist and, with appropriate redaction of personally identifiable information, a sample completed clinician file demonstrating what "cleared" looks like in practice. If an agency is reluctant to provide this documentation, that reluctance is itself the most informative answer to all twelve questions.
Embedding These Requirements in Your MSA
Verbal assurances have no evidentiary value in a survey, audit, or legal proceeding. Every credentialing standard you require from a staffing agency should be reflected explicitly in your executed Master Service Agreement — not in a side email or a verbal conversation with a sales representative. Work with your compliance team or legal counsel to ensure that your MSA template incorporates: the specific databases screened and the screening frequency; the primary source verification methodology; workers' compensation and professional liability insurance minimums with the facility named as additional insured; notification timelines for exclusion discoveries or license actions; and the agency's explicit assumption of responsibility for pre-placement credentialing, with the facility retaining responsibility for facility-specific access, privileging, and APP supervision agreements.
Hearthstone & Co. builds these standards into its Client Service Agreement v3 by default and is prepared to discuss and accommodate facility-specific credentialing requirements that exceed our standard checklist. We welcome the conversation.