5 Steps To Efficient Physician Credentialing

Physician credentialing is necessary to receive in-network reimbursement from insurance plans. Procrastination and haphazard processing can spell cash-flow disasters for your new provider. Fortunately, there are ways to minimize issues with credentialing. Here are five simplistic, yet proven, techniques to improve your credentialing success.

1. Start early. Be aware that most commercial insurance credentialing and contracting will take 90 – 120 days on average. Some plans are even slower, so don’t wait until the last minute. Many new practices or practices hiring a new provider make the mistake of beginning the process a month prior to a desired start date and then become frustrated when they cannot receive in-network reimbursement for another 3-4 months until the network contract process is complete. You must go through two processes with each insurance company; First, is the credentialing process where they verify all your education and training and then present your file to the credentialing committee for approval. The approval/rejection is based on their internal credentialing requirements. This first step typically takes around 90 days. Second, is the contracting process. The contracting process is where you are given the network contract for evaluation and execution. Only after your network contract is put into effect can you bill a commercial insurance company and receive in-network reimbursement. Commercial plan contracts do not have any retroactive billing provisions, so you will only be able to receive full reimbursement after your effective date.

2. Pay attention to the details. With such a lengthy process ahead of you, don’t delay your implementation by submitting credentialing applications with missing or incomplete information. Here are some of the most common errors found on payer enrollment applications:

  • Incomplete work history – you must include your current practice and all prior professional work history since graduating medical school and your history must include mm/yyyy format on all start/end dates;
  • Malpractice insurance – you must include your current policy and up to 10 years policy history;
  • Hospital privileges – you must have admitting privileges to an in-network hospital in order to participate with a health plan. If you do not, then you will need to have an admitting arrangement in writing with another in-network physician who will attest to an agreement to admit any of your patients that require in-patient services;
  • Covering colleagues – you are responsible for providing coverage for patients 24/7 and will need to disclose colleagues who cover for you when you are away. This is particularly important for solo practitioners;
  • Attestations – fully answer all yes/no questions on each application and provide complete details for response when necessary.

Getting your applications correct the first time will minimize the time delays for your new provider.

3. Stay current with CAQH. A current CAQH profile is an important part of commercial insurance credentialing. Make certain that your CAQH profile is current with all personal details, attestations, signature pages, and required documents. A majority of commercial payers utilize CAQH to retrieve the bulk of credentialing information. An incomplete profile will cause a delay in the process.

4. Require involvement from your new provider. When you hire a new provider, make sure he or she knows they are responsible for completing the credentialing process for all the payers with which your organization participates. Don’t think it is an inconvenience or offensive to a new provider to require them to complete necessary credentialing documents; it is their absolute responsibility. In order for the practice to be paid for their professional services, they must go through the credentialing and contracting process with each payer. Best practice would be to link a provider start date to completing primary payer credentialing. Build in punitive measures to employment contracts if a provider is uncooperative with credentialing.

5. Know your key payers. Know which payers represent 80% of your business so that you can prioritize credentialing to complete those payer processes first. You can selectively schedule patients for your new provider based on which plans have completed until the new provider is fully credentialed.

Credentialing is a tedious process. If you are not fully prepared with all necessary information to complete the process on first submission, you will cause delays in the process. It is a best practice to only begin the process with payers after you have compiled all information typically required during the payer credentialing process.

For information about outsourced credentialing services, contact National Credentialing Solutions (nCred) at (423) 443-4525, or visit their site for more information on provider enrollment services.

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