Important steps in medical credentialing

A practice thrives when it can strengthen the trust of patients. When the providers are credentialed, it gives assurance to the patients regarding the services provided at the practice. That is one of the factors that make credentialing so vital.

Undertaking the process of credentialing allows a practice to verify the credentials and expertise of the providers while also getting them classified as medically approved providers with the insurance companies it interacts with most frequently.

Even if insurance panels have already approved providers, providers need to reapply every time they start working for a new business. The process of medical provider credentialing can be costly and time-consuming, which can consume many of your practice’s resources.

Experts at Capline Healthcare Management have prepared a guide to help you review the six critical phases in provider credentialing to make the system more accessible and understandable.

Significance of credentialing in healthcare

Before we get started and talk about the key steps, it is essential to answer one question first. Why is credentialing so important? Answering this will help us get on the same page, and we can then move ahead to take on the nitty-gritty of the process.

Most facilities need to confirm that healthcare providers have sufficient credentials to handle insurance claims. Credentialing is crucial for ensuring broad healthcare coverage, even if some clients are uninsured or pay out of pocket.

Different healthcare providers have different physician credentialing processes. Credentialing is vital for providers, physical therapists, licensed therapists, counselors, psychologists, and other professionals.

To accept Medicare and Medicaid, you will have to ensure that your credentialing department complies with the following federal agencies’ requirements:

• The Joint Commission on Accreditation of Healthcare Organizations
• Centers for Medicare and Medicaid Services (CMS).
• The Joint Commission on Accreditation of Healthcare Organizations Centers for Medicare and Medicaid Services (CMS).

Each state has its certification standards in addition to federal regulations. Understanding and abiding by these guidelines can help your practice minimize its liability in the event of a malpractice claim.

Steps to the smooth credentialing process

Documents: What do you need, and what can be skipped.

Be informed that each provider requires different documents and forms when starting the credentialing process. In addition, each insurer you wish to work with will require comprehensive applications, and missing even a single minute piece of information might trigger a delay of weeks or months.

Make a list of every insurance provider you plan to get credentialed with to ensure your applications are comprehensive. Then, make a list of all the prerequisite documents to kick start the process. Some commonly sought documents include:

• Name
• Social security number
• Education proof
• Residency proof
• Career history
• Demographic information
• Claim history
• Specialty & Patient focus
• Information related to the healthcare facility
• Proof of insurance

Prioritize the insurers

You will be submitting multiple applications at a time. Being a little organized can come in handy. It might be beneficial to prioritize the dossiers and know which one to submit first. Make a priority list and start putting together documents and applications based on it.

• Complete one specific credentialing application first if a significant percentage of your medical billing goes through that specific insurer.
• Keep up with the regulations of each insurer. Some insurance companies, like Aetna, allow providers already insured in another state to go through an expedited process. That could result in faster approvals.
• Several insurers offer a shortened application for providers who are already credentialed in-state.

Accurate information is the key
When sequencing and completing your documents as per the procedures, remember that accurate and complete information is vital. So before you start submitting applications, ensure the following steps:

• Conduct a background check
• Verify the educational history, board certification, licensing, and reputation through health organizations like The American Medical Association, The educational commission for Foreign Medical Graduates Certification, The American Board of Medical Specialities, etc.
• Examine your credentials, privileges, and insurance claims history.
• List any sanctions filed with the Inspector General’s Office (OIG)

Any inaccuracies in the information given can cause problems. For instance:

• If prior employers cannot quickly and precisely verify months and dates of employment, amending the application with the correct information may cause a delay in the approval.
• Incorrect phone numbers for references or previous employers might also result in delays or denials.
• Failure to disclose past malpractice allegations could result in disqualification.

Complete the CAQH

Several large health-insurance companies require partner facilities to apply for certification through the Council for Affordable Quality Healthcare.

• Your practice will receive a CAQH number and an invitation to apply after applying with an individual insurer.
• You can choose to fill out the CAQH form on paper or online. This form, which is 50 pages long when printed, is best done on a computer (since the CAQH will have to manually enter the data on their end if provided on paper).
• Any erroneous or missing information can cause CAQH approval to be severely delayed, just as with individual insurer applications.
• Prepare to re-attest after submitting the initial application. What does re-attestation include? You must certify the accuracy of a provider’s information four times per year to preserve continuing insurance eligibility.

Verification

It’s time to wait for insurers to approve your application after putting it together and submitting it. It might be a time-consuming procedure. While most credentialing can be done in 90 days or less, experts recommend allowing 150 days. Credentialing can take even longer if significant complications occur.

Follow-up

It is best not to wait five or six months and leave things to chance. Consistent follow-ups are crucial to quick approval, according to credentialing healthcare experts.

Develop ties with critical insurance industry personnel. Establishing a rapport with leadership, executive assistants, and other employees can aid in the speedy processing of applications.

To increase your chances of receiving a response, check in by phone rather than email. If you discover that extra information is needed, gather and check all papers as soon as possible.

Too much information, too less time- Call the experts at Capline Healthcare Management.

Working with insurance companies can gobble up a lot of time and money for you and your practice. Negotiating payment contracts, in addition to credentialing, is a time-consuming process that requires your constant attention. After all, insurers change the terms of their payment contracts, often hoping that you’ll be too preoccupied with other paperwork to negotiate a better deal.

Capline Healthcare Management is here to help you. We are known for the best-in-class credentialing services for providers, and we can take it from here for you. It is time to rely on our extensive network and efficient teamwork, and trust us to get you through the process without much hassle.