Provider Enrollment and Credentialing Services

When your facility hires a new physician, nurse practitioner, or another healthcare provider, it’s essential to move them through the medical credentialing process. This allows you to verify their qualifications and skills while getting them listed as a medical approved provider by the insurance companies you most frequently work with.

Even if a healthcare provider has been approved by insurance panels in the past, they need to reapply each time they begin work with a new employer.

Unfortunately, medical credentialing is a time-consuming and expensive process that can occupy much of your facility’s resources. To make the system more transparent, experts here at created a guide to help you review the six key steps in provider credentialing.

The Importance of Credentialing

Before we start discussing the steps, let’s answer the question of, why is credentialing important in healthcare to get on the same page about the importance of healthcare credentialing, also known as insurance credentialing.

Most facilities need to ensure their healthcare providers have proper credentials in order to process insurance claims. Even if some of your clients are uninsured or pay out-of-pocket, credentialing is important for providing broad access to care. 

There are unique physician credentialing processes for different healthcare providers. While the process is vital for physicians, credentialing is also important for:

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

To accept Medicare and Medicaid, you’ll need to ensure your credentialing department meets guidelines from the following federal agencies:

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

Beyond these federal regulations, each state has its own credentialing requirements. Understanding and closely following these requirements can help reduce your practice’s liability in the face of potential malpractice claims.

Yet, as we noted, credentialing is time-consuming and even tedious. To make sure your medical provider receives proper credentials in a timely manner, follow these steps.

#1 Identify the Required Documents

As you begin the credentialing process in healthcare, be aware that each insurer requires different documentation and forms. You’ll need to submit complete applications to each insurer you plan to work with—and 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.

These often include but are not limited to:1

• 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

Hopefully, much of that information was reported in your provider’s resume and application. However, you’ll need to take steps to ensure its accuracy.

#2 Prioritize Insurers

Because you’ll need to submit multiple applications, it may be advantageous to prioritize which dossiers you submit first.

• If a significant portion of your medical billing goes through a single insurer, complete their credentialing application first.
• Stay familiar with individual insurers’ regulations. Some insurance companies—for example, Aetna—allow a streamlined process for providers who are already insured in another state.2That may mean quicker approvals.
• Other insurers provide an abbreviated application for providers who are already credentialed in-state.

Make a list of your priorities and begin to assemble documents and applications accordingly.

#3 Check for Accurate Information

As you begin to assemble required documents and begin individual applications, keep in mind that the quality and accuracy of information is key.

Before submitting any application, take the following steps:

• Conduct a background check
• Verify educational history, licensing, board certification, and reputation through healthcare organization such as:
• The American Medical Association (AMA)
• The Educational Commission for Foreign Medical Graduates Certification (ECFMG)
• 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)

Any errors in the submitted information can cause issues. For example:

• 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.
• Omissions of past malpractice claims could be disqualifying.

Once you’ve assembled and verified these documents, you’re ready to present them to facility leadership, who will determine the specific privileges to grant to the new provider. This information is vital for the credentialing application.

Manual Verification vs. Other Methods

Should your facility manually verify provider information or use an alternate method?

Some healthcare facilities choose to credential the old-fashioned way, calling and emailing medical schools, the American Medical Association, and other key organizations to verify the information on a provider’s resume.

However, this can be incredibly time-consuming, and any cut corners could result in further delays.

Other options include:

• Credentialing software– Programs like Modio and Ready Doc automate parts of the credentialing process by cross-referencing resume and application information with AMA profiles, medical schools, the OIG, and more. 
• Outsourcing– Is your HR department overwhelmed with credentialing? Outsourcing and utilizing a credentialing service can potentially save precious time and money. 

Once you’re sure you have accurate information, you can proceed to the next step.

#4 Completing the CAQH

Several major healthcare insurers require partner facilities to apply for credentialing through the Council for Affordable Quality Healthcare (while also completing their individual applications).3

• Once your facility 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. Running to 50 pages when printed, this form is most efficiently completed on a computer (since the CAQH will have to manually enter the data on their end if it is provided on paper).
• As with applications to individual insurers, CAQH approval can be significantly delayed by any inaccurate or incomplete information.
• After submitting the initial application, be prepared to re-attest. What is re-attestation? To maintain continuous insurance eligibility, you’ll need to attest that a provider’s information is correct four times each year.

#5 Wait for Verification

Once you’ve assembled and submitted your application to insurers, it’s time to wait for their approval.

This can be a lengthy process.

While most credentialing can be completed within 90 days, experts suggest giving yourself 150 days.4 If serious issues arise, credentialing can take even longer.

#6 Following Up 

Don’t just wait five or six months to hear from an insurer. Credentialing healthcare professionals reveal that consistent follow-ups are key to timely approval.

• Cultivate relationships with key personnel at the insurance company. Established rapport with leadership, executive assistants, and other staff can help ensure that applications move along in a timely manner.
• Check-in via phone rather than email to maximize the chance of a response.
• If you find out that more information is required, compile and verify all documents in a timely manner.

#7 Recertification

Eventually, your provider will receive their insurance panel credentialing. However, that doesn’t mean they’ll be credentialed forever.

Unfortunately, credentialing is an ongoing process that requires more work down the line.

• If you discover an error in an employee’s information, it’s important to notify insurers. If they notice the erroneous information before you submit a formal correction, it could be grounds for revocation.
• Most providers need re-credentialing every three years.

As we’ve noted, credentialing software can help you manage credentialing. Likewise, it should notify you when it’s time to renew a specific provider’s credentials.

However, insurers should also send a notification after three years have elapsed. Respond in a timely manner to ensure your provider can provide patient care without interruption.

Talk to the Softlogan team about the best practices of Credentialing