What Is The Importance of Provider Credentialing?

What Is The Importance of Provider Credentialing?

Let’s begin by addressing the fundamental question: Why is healthcare provider credentialing so crucial? By knowing about the significance of healthcare provider credentialing, which is also referred to as payer credentialing or medical credentialing, we can establish a shared understanding before moving on to the steps involved.

In healthcare, proper credentialing for providers is essential for multiple reasons. It serves as the foundation for processing insurance claims effectively across various facilities. Even in cases where patients are uninsured or opt for out-of-pocket payments, credentialing plays a pivotal role in ensuring widespread access to comprehensive care.

Different healthcare provider specialties entail specific physician credentialing processes. While this process remains integral for physicians, dentists and mid-level providers, it is equally vital for the following healthcare providers and organizations:

  • Physical & Occupational Therapists
  • Mental & Behavioral Health Providers
  • Medical Groups & Practices
  • Community Health Centers
  • Labs & DME Suppliers
  • Hospitals and Health Systems

What Are The Key Steps For Provider Credentialing?

When onboarding new physicians, nurse practitioners, or other healthcare providers to your facility, you must guide them through the medical credentialing process. This process ensures the validation of their qualifications and expertise and inclusion as an authorized medical provider or a network participant with the insurance companies your facility commonly collaborates with. Even if a healthcare provider has been previously accepted by insurance panels, they must undergo reapplication / reassignment whenever they commence employment with a new organization.

The scope extends further to encompass acceptance of government payers i.e., Medicare and Medicaid. Achieving this requires adherence to credentialing guidelines stipulated by Centers for Medicare & Medicaid Services (CMS) and The Joint Commission on Accreditation of Healthcare Organizations.

Beyond these federal directives, each state imposes its own unique set of healthcare credentialing guidelines. Thorough comprehension and diligent adherence to these guidelines can substantially reduce the potential liability concerning malpractice claims within your practice.

The process of medical credentialing is both challenging and time-intensive, often consuming a substantial portion of your resources. To expedite the acquisition of proper credentials for your healthcare providers, it’s imperative to meticulously follow the steps listed below:

Gather Necessary Documents

As you start with the provider credentialing process, it’s important to note that each insurance company has its own set of required documents and forms. It’s crucial to submit comprehensive applications to all the insurance companies you intend to collaborate with. Even the absence of a single piece of information can lead to significant delays in the approval process, spanning weeks or even months.

To guarantee the completeness of your applications, follow these steps:

✓ Compile a list of all the insurance companies you intend to engage with.

✓ Enumerate the specific documents and information required by each company.

These typically encompass, but are not restricted to:

  • Full Name
  • Social Security Number
  • Demographic Details
  • Educational and Training
  • State License
  • Malpractice Insurance
  • Board Certification
  • Professional History
  • Adverse Action Information
  • Information Pertaining to Your Practice or Facility Location

Organize Payer Priorities

Given that you’ll be submitting multiple applications, it could be beneficial to strategically organize the documents that you present.

If a considerable segment of your medical billing is facilitated via a specific payer, it’s advisable to commence with their credentialing application. Maintain familiarity with the distinct regulations of each insurer. Some payers offer an expedited process for providers who are already endorsed in another state. This might result in faster approval timelines.

Certain insurance providers also furnish condensed applications for those who have already received credentials within the state. Formulate a prioritized checklist and initiate the compilation of necessary documents and applications in alignment with these priorities.

Ensuring Accurate Documentation & Information

When preparing documents and applications, remember that accuracy is very crucial. Follow these steps before submitting any provider credentialing application:

✓ Perform a background check

✓ Verify education, licenses, board certification, references, clinical privileges, and reputation through trusted healthcare organizations like AMA, ECFMG, and the American Board of Medical Specialties

✓ Review credentialing, privileges, and insurance claims history

✓ Note any Office of Inspector General (OIG) sanctions

Errors in your submission can lead to problems, for instance:

✓ Inaccurate employment dates may delay approval

✓ Incorrect reference contact details can cause delays or rejections

✓ Neglecting past malpractice claims could disqualify you

Additionally, choosing between manual verification and alternative methods is also important. Some facilities manually verify by contacting organizations like AMA, but this takes time. Credentialing software can automate cross-referencing with AMA, medical schools, OIG, etc.

Fulfilling The CAQH Requirements

Majority of the well-known payers necessitate partner facilities to undergo provider credentialing via the Council for Affordable Quality Healthcare (CAQH), alongside completing their applications. This process is detailed below:

✓ Upon applying to a payer, your facility will receive a CAQH number along with an application invitation

✓ You will have the choice to either complete the CAQH form using traditional paper methods or opt for the more efficient online approach. Sometimes, this form spans approximately 50 pages when printed, making electronic completion preferable

✓ Any inaccuracies or omissions in the provided information could lead to significant delays in CAQH approval

✓ Subsequent to the initial application submission, readiness for re-attestation is required four times annually

Waiting For Payer Verification & Approval

Once you’ve compiled and submitted your application to payers, the next step is to await their approval. This phase may extend over a considerable duration. Although the credentialing procedure could theoretically conclude within 90 days, experts recommend allowing up to 150 days to account for potential delays. In cases of more intricate issues arising, the credentialing timeline might extend further.

Proactive Follow-Up

A proactive follow-up with payers is crucial to expedite the payer verification and approval process. Nurture connections with payer reps. Establishing a rapport with payer reps can facilitate the seamless advancement of applications. Prioritize direct phone communication as opposed to email to enhance the likelihood of a swift response. Should the payer request supplemental information, promptly compile and submit all requested information and documents.

Recertification Process

In due course, your healthcare provider will secure their insurance panel credentials. Nonetheless, this doesn’t signify a perpetual credentialing status. Healthcare provider credentialing constitutes an ongoing obligation that necessitates future attention.

For most providers, the process of re-credentialing arises every three years.

As previously mentioned, credentialing software can streamline your management of this process. It should also issue reminders when the time comes to renew a particular provider’s credentials. However, payers are expected to dispatch a notification once the three-year period has transpired. Swift response is crucial to guarantee uninterrupted patient care by your providers.

Get The Best Credentialing Services With Trained Professionals!

TriumpHealth is a trusted and reliable Provider Credentialing services provider. Their skilled team holds years of credentialing experience and has worked with multiple government, commercial and private payers. To learn more about their provider credentialing services, contact them at (888) 747-3836 x0 or email