Category: Healthcare Credentialing

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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.

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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.

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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.

BEWARE:

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.