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Medical Credentialing Guide
Tuesday, March 17, 2020

What Is Medical Credentialing?

Medical 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 months. 

  • Physicians
  • Non-Physician Practitioners
  • Podiatrists
  • Ophthalmologists
  • Optometrists
  • Dentists
  • Counselors
  • Social workers
  • Psychologists
  • Therapists 
  • Marriage and family therapists
  • Clinics, Group Practices, and other Certain Other Suppliers

Credentialing should be complete before a practitioner is allowed to provide patient care; otherwise, you might not be paid for your services.

Why Credentialing Is So Important

It's 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 important?"

1. Increased Patient Confidence

Credentialing 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.

2. Safeguards

Credentialing 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.

3. Healthcare Credential Management

Credential 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.

The Consequences of Not Being Credentialed

What happens when medical credentialing doesn't occur? There are situations that can be avoided by keeping all provider's credentials current. 

1. Ineligibility to Practice

A provider 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. 

2. Liability

Liability 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. 

3. Lost Insurance Revenue

If 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.

The Medical Credentialing Process

Before 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 process.

Collecting Information

The information collection stage is time-consuming on the provider's end. The credentialing organization will need information such as the following about the provider.

  • Contact Information
  • CAQH Access
  • National Provider Identification (NPI)
  • NPPES Access
  • Professional Licenses
  • Diplomas
  • Certifications and CMEs if not board certified
  • Professional References
  • Work history and education
  • Current CV
  • Malpractice liability 
  • Miscellaneous Information

It's 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.  

Conducting Background Checks

The 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. 

Verifying and Contacting Peers

Most 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.  

Investigating Malpractice

The 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 credentials.

Most 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. 

Sending Applications

After 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 application. 

Verifying Privileges

When 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. 

The Re-Credentialing Process

Periodically, providers must have their credentials re-evaluated. The frequency of re-credentialing depends on the state as well as the requirements of insurance companies. 

To 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 verification. 

Don't Go It Alone - Talk to Medical Credentialing Specialists 

Healthcare 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. 

For accurate and swift verification of medical credentials, call Secure Healthcare Services at (855) 973-1400 or contact us online.


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