What is Healthcare Credentialing

Healthcare Credentialing; Who Uses It And For What Purpose

Healthcare credentialing refers to the process of verifying education, training, and proven skills of healthcare practitioners.  Steps taken during the credentialing process include verifying license(s), identifying medical schools and verifying completion of medical education, verify training such as internships, residency, and fellowships, and other items.  Verification is done by going to the “Primary Source”, which means reaching out to the entity that provided the education, license, or other credential to verify the accuracy of the information given by the healthcare provider.  Verifying medical licenses for example means contact the state licensing board to verify the license is active and that there are no restrictions on the license; verifying education means contacting the medical school and verify that a degree was received.  The process can be very lengthy depending upon the specific items that need to be verified.

A credentialing process is utilized by healthcare facilities as part of its process to allow practitioners to provide services on its campus, health plans to allow providers to participate in its network (provider enrollment), medical group when hiring new providers, and other healthcare entities that have a need to hire or otherwise engage providers.

Provider Enrollment

Provider Enrollment refers to the process of requesting participation in a health insurance network as a Participating Provider.  The provider enrollment process involves requesting enrollment/contracting with a plan; completing the plans credentialing/enrollment application; submitting copies of licenses, insurance, and other documents; signing a contract; and any other steps that may be unique to a carrier.  Many commercial carriers utilize CAQH to obtain credentialing information from a central location, and require that providers have a complete and up to date profile in the CAQH system as part of the enrollment process.

When receiving a provider enrollment request, health plans use the credentialing process to ensure that the provider is properly educated, trained, and meet any other specific insurance network enrollment requirements for participation.  After credentialing process is complete, then the network will offer a contract for participation to the provider.

The provider enrollment processing time varies by payor.  Some commercial plans take as long as 180 days to complete the credentialing process and then another 30 – 45 days for contracting, while other have the entire credentialing and contracting complete within 90 days.  When submitting documents for enrollment, contracts, or following up on applications it is important to document your steps by utilizing certified mail, overnight mail services, email, fax logs, and documenting phone conversations with agent names and numbers.

There are many service companies that assist healthcare providers with the enrollment process for a fee.  These companies handle all the paperwork and follow up with the insurance companies on behalf of the provider.  The value of these services lie in the time saved and general expertise of dealing with insurance companies on a daily basis.

5 Steps To Efficient Physician Credentialing

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.

Credentialing New Physicians- It takes planning and perfect timing

It is always a good sign when your practice recruits a new physician fresh from medical school. It brings attention to your practice, and can help you build a reputation of being a forward-thinking practice that offers the newest and best patient care practices. Don’t let the credentialing process undermine those immediate benefits. Credentialing for a new physician requires advance planning and a fairly long lead time. As soon as you know the new physician will be joining your practice, you need to start the credentialing process. You want to make sure that as soon as s/he arrives at your door ready to begin seeing patients, they are also set up to bill properly.


If you have to wait for your new physician to receive practice credentials, you cannot bill for his/her patient services in the meantime. Billing for your non-credentialed physician will result in denied claims to government health programs and either denials or out-of-network claims by commercial plans. Claims that are improperly paid during this time period can lead to audit problems, such as demand for reimbursement repayment, and a possible investigation into your billing practices. Most third party payers will not retroactively reimburse your practice for the new physician’s patient services, so that isn’t an option either. If a patient receives care from a non-credentialed physician, the patient may have to self- pay. As you can see, it’s important to get the new credentialing done right and on time, the first time!

Credentialing is a detailed and sometimes laborious process. That’s what we do. We take care of the credentialing process. Whether you have a new physician, a transferring physician or need re-credentialing, call us. We can save you time, money, and frustration! In our next blog we will give you tips and insights on how to credential a new physician the right way- the first time.


Medicare enrollment now required for part D prescribing

Medicare Provider Enrollment Changes

Last last week, the Centers for Medicare & Medicaid Services (CMS) issued a final rule for Medicare Advantage and Medicare Part D that includes provisions directly affecting physicians. Beginning June 1, 2015, in order to prescribe under Medicare Part D, physicians or eligible prescribers must be enrolled in Medicare or, for those who have opted out of the program, have a valid affidavit on file with their Medicare contactor. Medicare Part D sponsors must deny pharmacy claims for providers who do not meet this criteria. See the entire final rule here.

CMS also finalized a proposal allowing the agency to revoke the Medicare enrollment of a physician or eligible professional who has a practice of prescribing Part D drugs that is abusive, fails to meet Medicare requirements or represents a threat to the health and safety of Medicare beneficiaries. CMS states it only plans to exercise this new authority in very limited and exceptional circumstances. Action related to this new provision may begin as early as July 22, the effective date of the rule.

Medicare Background Checks

Implementation of fingerprint-based background checks for Medicare Provider Enrollment

As part of the enhanced provider enrollment screening provisions of the Affordable Care Act (ACA) the Center for Medicare and Medicaid Services (CMS) is implementing fingerprint-based background checks for providers and suppliers in the “high” level risk category.  Initially, the new screening provisions will apply to newly enrolling DMEPOS suppliers, Home Health Agencies, and other providers and suppliers who have been specifically designated as high risk.

The fingerprint-based background checks will apply to all individuals with a 5% or greater ownership in an enrolling provider/supplier.  Once fully implemented, all individuals with 5 percent or more ownership in a high risk category supplier will be required to undergo fingerprint based background checks.

Fingerprints are preferred in electronic format from a finger-print based background check contractor (FBBC), but paper cards can be accepted on the standard federal form.  Providers will incur the cost of fingerprinting.

CMS will notify providers of the requirement and the provider will have 30 days from receipt of the notification to submit the information.  The notification letters will identify FBBC’s in the jurisdiction of the provider.  The provider will be responsible for the cost of fingerprinting.

For more detailed information, read the latest Medicare Learning Network article here. Details of the provision can also be found on the electronic code of federal regulations.

Medicare Revalidation Update

On November 4, 2013, CMS issued a notice of revision to reflect the current revalidation process.  Revalidation applies to all providers and suppliers who enrolled with Medicare prior to March 25, 2011.  Affected providers and suppliers must revalidate their information on file with CMS by March 2015.

CMS has announced that between now and 2015, local Medicare carriers (referred to as MAC’s) “will send out revalidation notices on an intermittent, but regular basis to begin the revalidation process for each provider and supplier.”  Furthermore, “Providers and suppliers must submit the revalidation application only after being asked by their MAC to do so”.

Where will letters be mailed?

For providers NOT in PECOS – the revalidation letter will be sent to the special payments or primary practice address because CMS does not have a correspondence address.

For providers in PECOS – the revalidation letter will be sent to the special payments and correspondence addresses simultaneously. If these are the same, it will also be mailed to the primary practice address. If you believe you are not in PECOS and have not yet received a revalidation letter, contact your MAC. Contact information may be found at http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/downloads/contact_list.pdf on the CMS website.

CMS will provide the MACs with a list of providers/suppliers requiring revalidation every 60 days beginning October 2013. Within 60 days of receiving the CMS list, MACs will mail the revalidation notices.

Providers and suppliers have 60 days from the date of the revalidation letter to submit the complete enrollment package (including fee payment when necessary).  A 60 day extension is available if more time is needed to complete the revalidation process.  Extension requests must be submitted to your MAC in writing (fax/email permissible) or via phone.

The burden is on the Provider or supplier to submit revalidation applications within 60 days of the date of the issued revalidation letter.  MAC’s do not have any further responsibility of notification prior to terminating a provider’s billing privileges.  So, it is important that every Provider and Supplier alert staff to be on the lookout for a revalidation notice from CMS if you have not yet revalidated your information.  You can proactively search information on the CMS website to determine if a revalidation letter has been mailed.