Physician Credentialing: What every Physician should know about? - Legion Healthcare Solutions

Physician Credentialing: What every Physician should know about?

Physician Credentialing or Doctor Credentialing or Medical Credentialing or Provider Credentialing names can be different but with same process. Every healthcare professional must apply for credentialing initially and then get re-credentialed in every two to three years. The time frame for every re-credentialing depends on the payer’s policies and state laws.

Credentialing every time can be a challenging task, updating each document to certification, healthcare providers need to be extra cautious during credentialing. Usually, the stipulated time frame for credentialing is between 30 days to 180 days on average, but if some documents are misplaced or new documents are demanded by the payer, it could lead to further delay.

Providers need to start process of Credentialing well in advance the required period of credentialing.  Nurses and Healthcare providers (vendors) are usually credentialed using the same system but with a less comprehensive approach.

The Centre for Medicare and Medicaid Services (CMS) and Joint Commission on Accreditation of Healthcare Organizations demand that healthcare providers should be credentialed before they can accept patients. Healthcare providers that do not follow the CMS credentialing regulations will certainly not be eligible for Medicare and Medicaid reimbursement. Most providers in the country follow both the regulations to get paid, while states have their own credentialing systems for providers to practice within their boundaries.

Other groups also have set rules to make credentialing easier for providers. Such groups include:

  1. The National Committee for Quality Assurance (NCQA)
  2. The Accreditation Association for Ambulatory Healthcare (AAAHC)
  3. Utilization Review Accreditation Commission (URAC)
  4. Det Norske Veritas (DNV)

How does Credentialing Process work for Providers?

Assemble all Information

Insurance companies or payers will demand all the information regarding the provider, it will include his or her background info, education, licenses, etc. Physicians will need to gather all the information and submit them through email or software of the insurance company.

Insurance companies usually work with a third-party company known as a credentials verification organization (CVO) to gather and verify all the information of the provider.

Verify the Information

The payer will do a complete background check, corresponding with your licensing agencies, medical schools, and other entities mentioned by the provider information. Payers might even opt for credentialing software to check the information made available online by various agencies. Many healthcare organizations that regularly do credentialing adopt a single software solution that can be used for collaboration and work management to organize and record all the provider’s information. It’s a single platform solution where the providers can get updates about various credentialing requirements.

Payers usually flag during this step if any information is missing or doesn’t match, leading to further scrutiny.

Credentialing the Provider

Insurance company, after verifying the provider’s information, provides the credentials to the provider without any delay. Payer can even decide to approve the provider as an in-network provider, making the provider a lucrative option for patients having its medical insurance.

What can make your Credentialing take a long time?

Credentialing can take a very long time, affecting the reimbursement and morale of the provider. In the most efficient case credentialing when both providers and payers work in sync, credentialing and in-network should be approved within 30 days. However, we have observed that the process does take close to 60 to 90 days, and for certain occasions, it might end up with more than 180 days.

The process is complicated if it’s through email, as the follow-ups can end up in spam or even ignored. It can be worst when the paper-based system is used, and then the payer enters all the information using a computer.

Credentialing can take more time for recent medical school graduates.

How to leverage the Council for Affordable Quality Healthcare (CAQH)?

Council for Affordable Quality Healthcare (CAQH) a not-for-profit organization that was formed by some of the country’s top insurance companies coming together. It has an online portal for all providers and payers called as Universal Provider Data source, also known as ProView. The portal gathers all information from the providers, including the professional background.

ProView relieves both providers and payers from the extra burden of going through the process of submitting and verifying. It’s estimated that CAQH’s website will have more than 1.4 million healthcare providers’ self-report information.

Completing the online application for CAQH: CAQH offers two options for submitting the credentialing application: Paper-based and online. LHS recommends you take the online application path; sending the paper-based application means that the CAQH will delay the information entered into the database.

Formatting the resume based on required dates: Formatting the resume dates based on the system requirements is imperative, it even demands that there are no time gaps when it comes to providers resume. Every gap must have a reason and must be accounted for in the resume to make the application go through.

Uploading the scanned documents: Uploading the scanned docs is one simple step, but providers mostly miss when the time comes about uploading the documents. Resulting in further delay of credentialing.

Re-attesting after every six months: Re-attesting is a simple and quick process every provider must do once every year to confirm all the information is accurate and up to date based on the profile. During re-credentialing process re-attested documents can help providers easing the process.

Credentialing in Healthcare is still regarded as difficult, and this is meant to change. Healthcare Providers can opt for outsourcing credentialing teams that work across various states and specialties. The outsourced team will have expertise in handling payers’ queries and could even get you a better deal in the insurance package. Legion Healthcare Solution is one such company that has team of an experienced credentialing team who have worked on the insurance side over the years.

To know more about how we do it and get a credentialing quote for your practice, please let us know: