Medical Credentialing 

Before we begin talking about the processes, let’s start by answering the question, “Why is credentialing important in healthcare?” This will ensure that everyone has the same understanding of the significance of insurance credentialing, which is another name for healthcare credentialing.

In order to guarantee that their healthcare personnel has the appropriate credentials, the majority of hospitals are required to check insurance claims. Credentialing is essential for giving care to a large population, even if some of your patients do not have health insurance or pay for their treatment out of cash.

Different types of healthcare providers each have their own individual systems for credentialing physicians. Although the process is essential for medical professionals, obtaining credentials is also essential for the following:

• Hospitals and health agencies
• Dentists
• Physical therapists
• Licensed massage therapists
• Counselors and psychologists

In order to participate in Medicare, you will need to guarantee that the credentialing department at your organization complies with the standards set forth by the following federal agencies:

Joint Commission on Accreditation of Healthcare Organizations (CMS) Centers for Medicare & Medicaid Services (CMS)

In addition to these rules at the federal level, each state also has its own set of standards for credentials. Your practice’s potential liability in the face of potential malpractice lawsuits can be reduced if you have a solid understanding of these standards and strictly adhere to them.

However, as we mentioned before, obtaining credentials can be a time-consuming and sometimes frustrating process. 

By following these procedures, you may ensure that your medical practitioner will obtain the appropriate credentials in a timely way.

Documents: What is required and what is optional?

Be aware that in order to initiate the credentialing process, each provider requires a unique set of documentation and paperwork to be filled out. A full application is required by any insurance you want to work with, and the omission of even the most insignificant piece of information could cause a delay of several weeks or months.

For the purpose of ensuring that your applications cover all bases, you should compile a list of all of the insurance companies with which you intend to pursue credentialing. After that, compile a list of all the necessary documents to get the process rolling in its initial stage. Among the most frequently requested documents are:

• Name
• Number associated with social security
• Evidence of education
• Evidence of residency
• History of one’s career
• Data pertaining to demographics
• Claim history, with a focus on specialty and individual patients
• Details concerning the medical centre where treatment is provided
• Documentation proving that one is insured

Focus on Insurers

You are going to send in many applications all at once. Having even a modicum of organization can be really useful. It might be helpful to rank the files in order of importance and determine which one should be turned in first. Create a list of priorities, and then begin putting together the necessary paperwork and applications based on that list.

If a large percentage of your medical billing goes through a certain insurer, you should start by completing one of their specific credentialing applications.

Maintain a level of familiarity with the rules imposed by each insurer. Some insurance firms, such as Aetna, make it possible for healthcare providers who are currently insured in another state to move through the application process more quickly. That might lead to approvals being given much more quickly.

Several different insurers give providers who are already credentialed in the state a streamlined application process.

Correct Information is Essential

Be sure to keep in mind the importance of providing information that is both correct and comprehensive whenever you sequence and finish your documents in accordance with the rules. Before applying, make sure:

• Background check.
• The American Medical Association, Educational Commission for Foreign Medical Graduates Certification, American Board of Medical Specialties, etc. can verify the educational history, board certification, licensure, and reputation.
• Check your insurance claims, privileges, and certifications.
• List Inspector General sanctions (OIG)
• Information errors can cause issues. 

For instance, if the applicant’s previous employers are unable to swiftly and accurately verify the months and dates of employment, revising the application with the right information could cause the approval process to be delayed.

Incorrect references and employer phone numbers might sometimes delay or deny applications.

Disqualification may result from failing to disclose malpractice allegations.

Perform the CAQH

Several major health insurers require their partner hospitals to submit an application for certification through the Council for Affordable Quality Healthcare.

• After applying to an individual insurer, your practice will be issued a CAQH number and an invitation to apply.
• The CAQH form can be completed either on paper or online. This form, which consists of 50 pages when printed, is best completed on a computer (since the CAQH will have to manually enter the data on their end if provided on paper).
• As with individual insurer applications, any incorrect or missing information might result in a significant approval delay for CAQH.
• Prepare for re-attestation following the submission of the initial application. What is included in re-attestation? To maintain insurance eligibility, you are required to verify the correctness of a provider’s information four times every year.

Verification

After putting together and submitting your application, it is now time to wait for insurers to decide whether or not to approve it. It’s possible that the process will take a long time. Although the majority of the credentialing process can be completed in 90 days or less, industry experts recommend allocating 150 days for the process. The granting of credentials can take considerably more time if there are substantial issues.

Follow-up

It is in your best interest to not sit about for five or six months and leave everything up to chance. According to specialists in healthcare credentialing, consistent follow-ups are a critical component in achieving prompt approval.

Establish connections with key persons working in the insurance sector. The speed with which applications are processed can be improved by cultivating relationships with those in positions of authority, executive assistants, and other staff members.

Checking in via phone rather of the email will improve the likelihood that you will receive a response from the recipient. If you find out that further information is required, it is imperative that you quickly collect and review all of the papers.

Recertification

Your provider will, at some point in the future, obtain their insurance panel credentialing. However, this does not guarantee that they will maintain their credentials indefinitely.

Regrettably, obtaining credentials involves a continuing procedure that will call for additional labour in the future.

It is imperative that you let the insurers know if you find an inaccuracy in the information pertaining to an employee. It is possible that they will revoke your license or permit if they discover inaccurate information before you provide a formal correction to it.

The majority of service providers are required to update their credentials every three years.

As was said earlier, credentialing software can provide assistance with managing credentials. In a similar fashion, it ought to inform you when it is time to update the credentials of a certain supplier.

However, when three years have passed, insurance companies should also send a notification to their customers. It is important that you respond in a timely manner so that your physician can continue to deliver uninterrupted patient care.

Final Words

You and your practice may find that dealing with insurance carriers consumes a significant amount of both time and money. In addition to the credentialing procedure, negotiating payment contracts is a time-consuming process that requires your whole attention throughout. Insurers are notorious for altering the terms of their payment contracts in the hope that their customers will be too concerned with other forms of documentation to negotiate a more favourable agreement.

You can rely on Aplus RCM to provide assistance. We are recognized as providing the most reliable credentialing services for providers, and we are able to continue handling everything for you from this point on. It is time to rely on our vast network and effective teamwork and to trust that we will guide you through this procedure with as little difficulty as possible.

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