If you hire a new physician, nurse, or any other healthcare practitioner, it is important to update them through the various medical credentialing processes. Provider credentialing is the process of establishing that these medical providers have the necessary qualifications for performing their medical services.
Even if a DME provider has been approved by the insurance panels initially, they need to reapply each time when they change their employers. This process is known as the re-credentialing process and is a periodic inspection of ensuring that each DME provider is still qualified and is open to practicing their service in the given network.
Unfortunately, medical credentialing and re-credentialing is an expensive and time-consuming process that can take away a lot of your resources’ productivity. To make the system a little more transparent, the experts of 24/7 Medical Billing Services have documented a guide to help you with the process of reviewing the six key steps involved with healthcare provider credentialing.
The Importance of Credentialing
Before we start with the discussion, let us answer the question, “why credentialing is an important practice in the healthcare domain?”
Healthcare credentialing, also known as insurance credentialing states that all healthcare facilities must ensure that their DME providers have the necessary credentials to process the insurance claims. Even if some of your patients are uninsured or wish to pay from their pockets, credentialing is an essential element for providing broad access to the necessary patient care.
For different healthcare providers, the physician credentialing and Re-Credentialing process is unique. While the process is necessary for the physicians, credentialing is also important for the:
- Hospitals and the healthcare agencies
- The dentists and the dental care providers
- Physical therapists
- Licensed massage therapists
- Psychologists and the counselors
To continue with Medicare and Medicaid, you have to ensure that your credentialing department meets with the guidelines provided by the below mentioned federal agencies:
- Centers for Medicare and Medicaid Services (CMS)
- The Joint Commission on Accreditation of Healthcare Organizations
Apart from these federal regulations, each state has its credentialing requirements. Following and understanding these requirements can help you in reducing your business liability in case of potential incorrect or malpractice claims.
As mentioned above, credentialing is a tedious time-consuming process. To ensure all your healthcare practitioners receive their credentials on time, follow the below-mentioned steps:
- Identify the required documents
Before you begin with the credentialing process, do remember that each insurer requires different forms and documentation. You must submit the completed applications to all the insurers that you plan to work with. Even if a single piece of information is missing, it can delay the approval by several weeks or months.
Make a list of all the insurance providers that you plan to work with. List all the required documents for each of these insurers. These include but may not be limited to:
- Demographic-related information such as gender, languages spoken, etc.
- Social security number (SSN)
- Proof of licensure
- Education and address information
- Claim history
- Insurance Proof and much more.
Hopefully, most of this information would be in your records with the practitioners’ resumes and applications. However, you must ensure all this information is accurate to date.
2. Prioritize the insurers
You must submit multiple applications and thus it can be helpful if you prioritize which dossiers you would need to submit first.
- If most of your medical billing goes to a single insurer, make sure to complete the credentialing with them at first.
- Stay updated with the individual insurers’ regulations and compliance. Some insurance companies allow a streamlined process for the providers who have their credentials updated in other states. It means quicker approvals.
- Some insurers provide an abbreviated application for those providers who are already credentialed with other states.
Assemble all the applications and the necessary documentation according to your priority list
3. Make sure all the information is accurate and updated
Before applying, you must ensure all the information provided is accurate and up-to-date. Before the final submission:
- Carry out the background check.
- Verify educational details, board certification, licensing, and goodwill via healthcare organizations such as AMA, ECFMG, etc.
- Review history of privileges, credentialing, and insurance claims.
- List any sanctions in the records of Office of Inspector General (OIG)
Any form of errors on the submission forms can lead to a lot of concerns:
- Make sure that the months and the dates of the employment are accurately verified by the past employers. Else it can delay the process of approval.
- Incorrect phone numbers or referral contacts can also create unlimited delays or even rejections.
- Omission of any past malpractice claims can also disqualify the credentialing process altogether.
Once all the documents are assembled and verified, you must present them to the management of your facility. They will determine the specific privileges that they will grant to the new healthcare provider. It is thus very vital information for the credentialing procedure and you must not miss it.
Manual verification vs. other methods
Should you manually verify all the provider information or use any other alternative verification process?
Some healthcare facilities choose to undergo the credentialing and Re-Credentialing process in an old-fashioned manner by calling and emailing the various reference medical schools, the American Medical Association, and other key associations for the verification of the information found on the resume of the practitioner.
However, this process is rather time-consuming and can result in further delays.
Other options include:
Credentialing software: There are some software programs available like the Ready Doc and the Modio that automates some of the credentialing processes by cross-referencing the application and the resume information with the AMA profiles and the OIG and other medical schools.
Outsourcing: Are you feeling overwhelmed with the credentialing process? Outsourcing an offshore credentialing service can save you tons of time and money.
Once you are certain about the accuracy of the information provided, you can move on to the next step.
4. Completing the CAQH
Many major healthcare insurers require their partner facilities to apply for the credentialing via the Council for Affordable Quality Healthcare (while also looking for their applications).
- Once you have applied with an insurer, they will provide you with a CAQH number and also an invitation to apply.
- You will also be given the option to complete the CAQH form online or on paper. The form is around 50 pages long and is most efficiently completed by a computer (since the CAQH will have to enter the data manually if it is done on paper).
- CAQH applications can get significantly delayed with incomplete or inaccurate information.
- After submitting the initial application, you must be prepared to re-attest. Re-attestation maintains the consistency of the insurance eligibility at least four times each year.
5. Wait for verification
Once the application is submitted to the insurer, you have nothing else to do but wait for their approval. It can be a rather lengthy process.
While most credentialing can be done within 90 days, experts suggest that you give yourself 150 days. In case of serious differences, credentialing can take even longer.
6. Follow up
If you do not hear from an insurer, it is important to follow up with them consistently as it can be the key to a timely approval. You can ensure it by:
- Fostering a relationship with key personnel of the insurance company. Establish a rapport with the leadership and other staff members to ensure that the applications make their way to their tables on time.
- Checking over a call instead of emailing to maximize the chances of a response.
- In case more information is required, compile and verify all the documents timely and submit them.
Eventually, your provider will receive their credentialing for the insurance panel. But it certainly doesn’t mean they will remain credentialed forever.
Credentialing is an ongoing process that requires constant updating and effort.
- In case of an error in an employee’s information, do notify the insurers. If they notice any erroneous information before you submit a correction, it could make way for the revocation.
- Most providers need to re-credential every three years.
Credentialing software can help you in managing credentialing and Re-Credentialing efficiently. Likewise, it should also be able to notify you when it is time to renew the credentials for a specific employee. Specific insurers should also send a renewal notice at the lapse of three years. Respond timely to ensure that your provider can continue his service inpatient care without any interruptions.
Tired of following it up with the insurers? Call in for the experts at 24/7 Medical Billing Services
Working with the insurers can take up a significant time of your resources. Negotiating the payments contracts is also another laborious process that requires constant attention.
24/7 Medical Billing Services can help. Outsourcing credentialing and re-credentialing process can free up a lot of your resources’ time for other important tasks because we know the importance of caring for your patients as that makes more sense.