Legion Healthcare Solutions

Understanding Provider Credentialing Process

Understanding Provider Credentialing Process

Basics of Provider Credentialing

When any healthcare organization hires a new physician, nurse practitioner, or another healthcare service provider, it’s essential to move them through the medical credentialing process. Provider credentialing allows you to verify providers’ qualifications and skills while getting them listed as approved providers by the insurance carriers. Even though a provider has been approved by insurance panels in the past, they need to reapply each time while beginning to work with a new employer or before adding into a new practice. Medical credentialing is a time-consuming process requiring a lot of correct documentation. For understanding the provider credentialing process in detail and to remove any confusion, experts here at Legion Health Care Solutions shared step by step guide on provider credentialing.

List of Insurance Carriers

Make a list of insurance carriers you want providers to get credentialed with. This list will depend upon your healthcare organization’s location and patient mix. You can review your current patient data to list out the top ten insurance carriers. If a significant portion of your medical billing goes through a single insurance carrier, complete their credentialing application first. Understand every insurance carrier’s regulation and credentialing guidelines. Some of them for example, Aetna, allow a streamlined process for providers who are already insured in another state. That will result in quicker provider credentialing.

Complete Documentation

Provider credentialing starts with the timely submission of accurate documentation. Each insurance carrier requires different documentation and forms. You’ll need to submit complete applications to each insurance carrier you plan to work with. Having complete and accurate documentation is key because even a single missing piece of information can delay approval by weeks or months. To ensure your applications are complete, make a list of all insurance providers you plan to file with. Then, list out any and all required documents, this list includes but is not limited to:

  • Name
  • Social security number
  • Demographic information (ethnicity, gender, citizenship, languages spoken)
  • Education and residency information
  • Proof of licensure
  • Career history
  • Specialties and patient focus
  • Claim history
  • Proof of insurance
  • Information about your healthcare facility

Check for Document Accuracy

Most of the time above mentioned information is available in your provider’s resume and application. You can cross-check that information for ensuring accuracy. Any errors in the submitted information can cause issues. If months and dates of employment are not easily and accurately verified by past employers, revising the application with the correct information can delay the approval process. Likewise, incorrect phone numbers for references or past employers can create delays or even rejections.  To ensure accurate documentation you can follow a few steps:

  • Conduct a background check
  • Verify educational history, licensing, board certification, and reputation through healthcare organizations such as the American Medical Association (AMA); the Educational Commission for Foreign Medical Graduates Certification (ECFMG), or the American Board of Medical Specialties
  • Review history of credentialing, privileges, and insurance claims
  • List any sanctions recorded with the Office of Inspector General (OIG)

Completing CAQH

The Council for Affordable Quality Healthcare® (CAQH) is a web-based solution used to capture and share accurate, timely, electronic, self-reported provider data used for provider credentialing. Several major insurance carriers require partner facilities to apply for credentialing through the CAQH. When you’re first getting credentialed with health plans, sometimes payers will use your CAQH application/profile and export it into their system. Once your practice has filed an application with an individual insurer, they’ll provide a CAQH number and an invitation to apply. You’ll be given the option to complete the CAQH form on paper or online. After submitting the initial application, be prepared to re-attest. To maintain continuous insurance eligibility, you’ll need to attest that a provider’s information is correct four times each year.

Wait for Reply

Once you’ve assembled and submitted your application to payers, it’s time to wait for their approval. This can be a lengthy process. While most credentialing can be completed within 90 days, we suggest giving yourself 150 days. If serious issues arise, credentialing can take even longer.

Follow Up

Don’t just wait five or six months to hear from an insurance carrier. Consistent follow-ups are key to timely approval. Cultivate relationships with key personnel at the insurance company. Check in via phone rather than email to maximize the chance of a response. Establishing rapport with leadership, executive assistants, and other staff can help ensure that applications move along in a timely manner. If more information is required, compile and verify all documents in a timely manner before submitting them.

Working with insurance carriers to get provider credentialed is a tedious process and can consume a significant portion of your healthcare practice’s resources. After successful credentialing, negotiating payment contracts is another laborious process that requires your continuous attention. After all, insurers constantly change the terms of their payment contracts. Legion Health Care Solutions can assist you in provider enrollment and credentialing. We are a leading medical billing company that can assist you in revenue cycle functions for your practice. You can free your time for patient care by outsourcing your credentialing requirements with us. Contact us at 727-475-1834 or email us at info@legionhealthcaresolutions.com to know more.

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