Medical Credentialing GuideTuesday, March 17, 2020
Is Medical Credentialing?
credentialing is the process by which insurance companies, healthcare
organizations and hospitals obtain and evaluate documentation including a
healthcare provider's qualifications, including career history, education,
training, residency and licenses, regulatory compliance record, malpractice
history and any specialty certificates. Credentialing should be done as early as
possible because for some insurance
plans because it can take up to 3-4
- Non-Physician Practitioners
- Social workers
- Marriage and family therapists
- Clinics, Group Practices, and other Certain
should be complete before a practitioner is allowed to provide patient
care; otherwise, you might not be paid for your services.
Credentialing Is So Important
clear that healthcare professionals should have their skills and records
verified in order to protect patients and your practice, but
here are three other answers to the question, "why is credentialing
Increased Patient Confidence
is a way to ensure patients can have the utmost confidence in the ability of
their healthcare providers. Patients that have a credentialed provider with
their insurance can be assured that the provider is an in-network provider,
which could lessen their expenses.
ensures that providers are duly qualified, licensed, and do not have an
extensive history of malpractice claims, state or federal instituted sanctions
or other unfavorable professional circumstances.
Healthcare Credential Management
management is an important and essential function for provider groups, hospitals
and others which precedes hiring or obtaining coverage by an insurance carrier.
Credentialing can never be taken lightly! It protects the organization from
potential lawsuits and it ensures that providers are qualified to do the
position that they are being hired to do.
Consequences of Not Being Credentialed
happens when medical credentialing doesn't
occur? There are situations that can be
avoided by keeping all provider's credentials current.
Ineligibility to Practice
can practice in a facility without their
credentials in place. Even if they are in the process of completing or renewing
their credentialing, they will not be able to work in a credentialed facility.
Do note that medical students, fellows and residents don't require credentials,
assuming that their duties do not exceed the scope of their current training
program. Once training is over, however, they will have to go through the full
process in order to practice.
cases would include a review of the accused provider's
credentials. If they are lapsed or were never obtained, or if the practice is
negligent in the credentialing process, your organization may be held liable.
Not only does this lead to expensive legal fees and fines, it dramatically
lowers organizational reputation.
Lost Insurance RevenueIf timely credentialing of a
provider is not done, insurance companies will not pay an in-network
payment for claims by this provider or not pay at all and could result in a
significant amount of lost revenue for each provider. In addition, patients
could leave a practice for a participating provider.
Medical Credentialing Process
diving into the process of how to get credentialed with insurance companies and
other healthcare organizations, it's important to have an overview of what the
process is like. Here are the main steps in the provider credentialing
information collection stage is time-consuming on the provider's end. The
credentialing organization will need information such as the following about the
- Contact Information
- CAQH Access
- National Provider Identification (NPI)
- NPPES Access
- Professional Licenses
- Certifications and CMEs if not board
- Professional References
- Work history and education
- Current CV
- Malpractice liability
- Miscellaneous Information
important that credentialing organizations provide explicit
instructions to the providers on their applications. There is typically quite a
long list of requirements and copies needed, which becomes
even longer when the provider is applying for specialty credentials. Applying
providers need to know what to include, what to leave out and when the deadline
is to return all the information.
background check is the longest portion of the provider credentialing process.
This step involves going through all the information the provider has supplied
and verifying that it is truthful and accurate. Also, you must
check with the Office of Inspector General's Exclusion List (https://exclusions.oig.hhs.gov/) of
any medical professional.
and Contacting Peers
organizations require references from three physicians in the same specialty of
the applicant, who aren't related by blood or marriage and who are not members
of the applicant's practice. The credentialing organization must verify these
peers and contact them for further verification.
credentialing organization will read through any instances of malpractice found
in the National Practitioner Data Bank and
evaluate whether any present malpractices should bar the provider from receiving
applications have a space for the provider to acknowledge any malpractice claims
and provide context to the situation. If there is malpractice on the record,
this is cause for extra scrutiny through the rest of the process.
all, information is received and reviewed, it is time for the provider
application to go to the healthcare organization's governing body for review.
They will let you know if there are any red flags or missing information on the
a doctor applies for privileges at a healthcare organization, they get a list of
procedures approved by Medicare for their specialty to practice. If they want to
perform any procedures outside the list, the healthcare organization must verify
that the physician has received the appropriate training.
providers must have their credentials re-evaluated. The frequency of
re-credentialing depends on the state as well as the requirements of insurance
make the process more streamlined, insurance
companies are collaborating with medical credential companies
to make verification of information more efficient. The Council for Affordable
Quality Healthcare (CAQH), for example, has a database that providers can use to
compile information related to credentialing. However, the organization doing
the credentialing still has a significant amount of work to do in terms of
Go It Alone - Talk to Medical Credentialing Specialists
insurance credentialing is a long and tedious process, especially when you don't
have an in-house expert to speed up the process. Medical credentialing companies
like Secure Healthcare Services understand the importance of credentialing and
provide the most efficient path to achieving or renewing it.
accurate and swift verification of medical credentials, call Secure Healthcare
Services at (855) 973-1400 or contact us online.