It’s critical to move a new physician, nurse practitioner, or other healthcare providers through the medical credentialing process as soon as possible after they join your facility.
This allows you to confirm their qualifications and skills while also getting them listed as a medically approved provider with the insurance companies you work with the most.
Even if an insurance panel has previously approved a healthcare provider, they must reapply each time they start working for a new employer.
Medical credentialing, unfortunately, is a time-consuming and costly process that can consume a significant portion of your facility’s resources. To help you understand the six key steps in provider credentialing, experts created a guide.
Credentialing and Its Importance
To get everyone on the same page about the importance of healthcare credentialing, also known as insurance credentialing, let’s answer the question of why is credentialing important in healthcare.
In order to process insurance claims, most facilities must ensure that their healthcare providers have proper credentials. Credentialing is important for providing broad access to care, even if some of your clients are uninsured or pay out of pocket.
Different healthcare providers have different physician credentialing processes. While credentialing is essential for physicians, it is also necessary for:
- Hospitals and health-care organizations
- Dentists
- Occupational therapists
- Professional massage therapists
- Psychologists and counselors
To accept Medicare and Medicaid, make sure your credentialing department complies with the following federal agencies’ requirements:
- Medicare and Medicaid Services (CMS) (CMS)
- The Joint Commission on Healthcare Organization Accreditation
Each state has its own credentialing requirements in addition to the federal regulations. Understanding and adhering to these guidelines can help your practice reduce its liability in the event of a malpractice claim.
Credentialing, on the other hand, is time-consuming and even tedious. Follow these steps to ensure that your medical provider receives proper credentials in a timely manner.
1. Determine which documents are required
Be aware that each insurer requires different documentation and forms as you begin the credentialing process in healthcare. Each insurer you plan to work with will require complete applications, and even a single missing piece of information can cause approval to be delayed by weeks or months.
Make a list of all insurance providers you plan to file with to ensure your applications are complete.
Among them are, but are not limited to:
- Name
- Number of Social Security
- Information on demographics (ethnicity, gender, citizenship, languages spoken)
- Information on education and residency
- Proof of certification
- Work experience
- Patient-centered specialties
- Insurance proof of claim history
- Information about your medical Centre
Much of that information should have been included in your provider’s resume and application. You must, however, take steps to ensure its accuracy.
2. Give Insurers Priority
Because you’ll be submitting multiple applications, prioritizing which dossiers to submit first may be beneficial.
- Complete their credentialing application first if a significant portion of your medical billing goes through them.
- Keep up with the regulations of individual insurers. Some insurance companies, such as Aetna, allow providers who are already insured in another state to go through a streamlined process. 2 This could result in faster approvals.
- For providers who are already credentialed in-state, some insurers offer a shortened application.
Make a priority list and start assembling documents and applications accordingly.
3. Verify that the information is correct
As you begin to gather required documents and fill out individual applications, remember that information quality and accuracy are critical.
Take the following steps before submitting any application:
- Perform a background investigation
- Through healthcare organizations such as:
- The American Medical Association is a professional organization that represents doctors in the United States (AMA)
- The Educational Commission for the Certification of Foreign Medical Graduates (ECFMG)
- The American Board of Medical Specialists is a group of doctors who specialize in different fields of medicine.
- Examine your credentials, privileges, and insurance claims history.
- List any sanctions filed with the Inspector General’s Office (OIG)
Any errors in the information submitted can cause problems. For instance:
- If past employers cannot easily and accurately verify months and dates of employment, revising the application with the correct information may cause the approval process to be delayed.
- Failure to disclose past malpractice claims could result in disqualification.
You’re ready to present these documents to facility leadership once you’ve assembled and verified them. They’ll decide what specific privileges to grant the new provider. The credentialing application requires this information.
Other Methods vs. Manual Verification
Should your facility verify provider information manually or use a different method?
Some hospitals prefer to credential providers the old-fashioned way, by calling and emailing medical schools, the American Medical Association, and other key organizations to confirm the information on a provider’s resume.
However, this can take a long time, and any shortcuts could lead to even more delays.
Other possibilities include:
- Credentialing software – Programs like Modio and Ready Doc automate parts of the credentialing process by cross-referencing resume and application information with AMA profiles, medical schools, the Office of Inspector General, and other databases.
- Outsourcing- Is your HR department drowning in credentials? Using a credentialing service and outsourcing can potentially save time and money.
4. Finishing the CAQH
Several major health-insurance companies require their partners to apply for credentialing through the Council for Affordable Quality Healthcare (while also completing their individual applications).
- Your facility will receive a CAQH number and an invitation to apply after filing an application with an individual insurer.
- You will have the option of filling out the CAQH form on paper or online.
- Prepare to re-attest after submitting the initial application. What does re-attestation entail? You must attest to the accuracy of a provider’s information four times per year to maintain continuous insurance eligibility.
5. Wait for Verification
It’s time to wait for insurers to approve your application after you’ve put it together and submitted it.
This can be a time-consuming procedure.
While most credentialing can be completed in 90 days or less, experts recommend allowing 150 days.
4 Credentialing can take even longer if serious issues arise. (Click the provided link to learn more about healthcare credentialing issues!)
6. Next Steps
Don’t expect to hear from an insurer in five or six months. Consistent follow-ups are crucial to timely approval, according to credentialing healthcare professionals.
- Develop relationships with key insurance company personnel. Establishing a rapport with leadership, executive assistants, and other employees can aid in the timely processing of applications.
- To increase your chances of receiving a response, check-in by phone rather than email.
Certification Renewal
Your provider will eventually be approved by an insurance panel. That doesn’t mean they’ll keep their credentials indefinitely.
Unfortunately, credentialing is an ongoing process that will necessitate additional effort in the future.
- Re-credentialing is required for most providers every three years.
- As previously stated, credentialing software can assist you in managing credentials.
- However, after three years have passed, insurers should send a notification. Respond quickly to ensure that your provider can continue to provide patient care without interruption.
