The ultimate physician credentialing checklist

Physician credentialing is a standard process performed under a series of guidelines defined by the regulatory authorities. A process ensures whether the medical providers are capable enough to provide the highest level of patient care by verifying their qualifications, training, licensure, and ability to practice medicine. We know that a process is formidable for physicians to follow as it consumes significant time. Still, since it is required for all medical practitioners, we provide you with an ultimate physician credentialing checklist that would provide ease in following the process.

Importance of physician credentialing

As per the laws defined by the regulatory authorities, the hospital and health agencies, dentists, physical therapists, licensed massage therapists, Counselors, and psychologists must move through the medical credentialing process when hiring a new physician or nurse practitioner, or another healthcare provider. Therefore, If you are seeking the continuous development of your medical organization, there are a few reasons you should consider providing value to your facility’s credentialing practices and ensure the process is done correctly every time.

• Credentialing builds the trust of providers in the patients
• Credentials are Necessary for Earning Money
• Minimizes the rate of medical errors in the practices
• Protects you from Lawsuits
• Boosts Your Reputation as a medical provider

Ultimate physician credentialing checklist

Before a core process of physician credentialing gets to be started, the initial requirement for the medical organization is to ensure your credentialing department meets guidelines from federal agencies, including the Centers for Medicare & Medicaid Services (CMS) and the Joint Commission on Accreditation of Healthcare Organizations. Beyond these federal regulations, credentialing requirements vary from state to state. Hence, sticking to these requirements can help you reduce your practice’s liability for processing malpractice claims. To ensure your medical provider receives proper credentials promptly, follow these steps:

Collection of required documents

The first and foremost step in the medical credentialing process is the collection of the required documents from the physician. Requirements for the credentialing documents vary from payer to payer, so you must ensure the accuracy of the information you submit to the insurance carrier you plan to work with, as a single missing piece of information can delay approval by weeks or months. Most Probably, providers submit the information in a questionnaire format through email or software. Still, in most cases, medical organizations work with a third-party credentialing verification company that engages directly with a provider to gather and verify information more efficiently.

Common information requested to credential healthcare professionals

If you list all the insurance providers you plan to work with and list out all the required documents, it will ease you to ensure your applications are complete. Following is the most commonly requested information by the Payer.

Prioritize insurers

Medical organizations have financial relationships with several insurance carriers hence they have to submit multiple applications at a time. It may be advantageous to prioritize which documentation is essential to submit first. You can assemble documents and applications under the following circumstances:

• An insurance company with which your practice management has a significant involvement could have a greater preference in completing their credentialing application in the first stage.
• Some insurance companies give feasibility to the provider in the process of credentialing, which means you can expect a quick approval from them, who are already insured in another state. Therefore, It would be beneficial for you to stay familiar with individual insurers’ protocols. Moreover, specific payers provide abbreviated applications for the already credentialed providers in-state.

Check for the quality and accuracy of the information

While processing a physician credentialing, you must maintain quality and accuracy as you assemble the required documents and begin the individual applications. Make sure the past employers accurately verify the month and dates.
similarly, incorrect phone numbers for references can create delays or even rejections. You must include any malpractice claims of the physician, as omitting it can cause disqualification. Once you implied all the necessary checks on your documents, you can present them to the faculty leaders, who will assign specific privileges to the new provider.

Complete the CAQH

CAQH is an Online Data repository of credentialing data where insurance companies electronically access practitioners’ data, including their demographics, education, training, work history, and malpractice history. Almost every medical organization applies for credentialing through the Council for Affordable Quality Healthcare because it reduces the burden of paperwork by eliminating much of the paper-based enrollment process involved with payor network enrollment and facility privilege applications. This is a free-of-cost service; however, the insurance company must notify CAQH to invite the provider to join CAQH to create, update, and maintain their directory information before the provider can upload their information into the CAQH Proview.

Critical steps involved in completing the CAQH:

• Once your faculty are registered with CAQH ProView, they will be assigned a unique CAQH number and invitation to apply.
• You will have an option to complete the CAQH form on paper or online. You will complete the online application and review the data.
• Authorize access to the information
• Verify the data and/or attest to it
• Upload and submit supporting documents.

Wait for the approval of the application

Once you have applied to the concerned insurance carrier, most of the payers approve the credentialing application within 90 days. Still, the experts suggest appliers expect 150 days from the insurance carrier to complete the process. If serious issues arise, credentialing can even take longer.

Insurance follow-up

It is a fact that the insurance carrier takes a significant time to get your credentialing application approved, but it doesn’t mean you keep on waiting for five to six months to hear from the Payer. The key to getting timely approval for your application is to build consistent follow-ups with Payers.

Take the following necessary steps to ensure timely approval of your application:

• Establish a friendly and harmonious relationship with the key personnel at the insurance company, including the executive assistants and other staff members that can help you in assuring the application is moving along promptly
• Prefer to contact with insurance carrier through a phone call instead of email or fax, it will maximize the chance of a response from Payer
• If Payer asks for more information from you, then compile and verify all documents promptly

Re-credentialing

Once your physician is credentialed from the Payer, it doesn’t mean he will be credentialed forever because credentialing is an ongoing process that requires more work down the line. If you find any error in the physician’s information, it is crucial to notify insurers promptly for the formal correction before they notice any erroneous information; it would the grounds for revocation. Most insurance carriers require providers to renew their credentialing every three years.
You can use credentialing software to help you manage credentialing; It would notify you when your credentialing is near expiration. However, insurers also send notifications to remind you to renew your credentialing. You should respond to their disclosure promptly to ensure your physician provides healthy medical services without interruption.

Healthcare credentialing FAQs

How often should healthcare providers be “re-credentialed”?

According to the standard Payer regulations, healthcare providers must renew their credentialing every three years. While some insurance companies perform re-credentialing even more often.

Can healthcare providers make corrections in their credentialing information?

Healthcare providers have a right to review their credentialing information during the whole process and can formally correct any erroneous information if found.

What is primary source verification?

The healthcare facilities require primary source verification to confirm that their medical provider possesses a valid license, certification, or registration from the agency granting licenses or certificates to ensure the physician is capable enough to practice a profession.

What’s the difference between “credentialing” and “privileging”?

Privileging: The process where the hospital authorizes the provider by letting them perform specific medical procedures and practice certain types of medicine at the facility for evaluation is referred to as a privilege. For example, a physician may acquire a medical license for specific medical practice, such as an obstetrician but isn’t qualified to perform heart surgery. A medical organization assigns privileges to a provider based on his or her medical background and skills.

Credentialing: It is a process of verification performed by the healthcare facilities for the physicians to make sure they are eligible to perform different medical procedures in the facility. The verification includes double-checking physicians’ licenses, certificates, and other titles in good standing to do their job.

Why should you acquire a modernized provider credentialing and enrollment Process?

Working with insurance companies requires excessive time and resource allocation from your healthcare faculty; moreover, negotiating payment contracts is another laborious process that needs consistent attention. In these circumstances, MedsIT Nexus medical billing and coding services can help you streamline the provider credentialing and enrollment process by reviewing and gathering documentation through billing and coding software which completely eliminates the chances of getting a rejection of a credentialing application from the Payer.