Provider Credentialing

Provider credentialing is more than just another form to fill out or a minor nuisance; it’s a complex, ongoing process and a critically important one at that. Without successful credentialing, provider reimbursement for medical services can be delayed and, even, denied. Given its many steps, critical deadlines and lurking uncertainties, provider credentialing is business critical for your practice.

EMR-Dr simplifies the credentialing process for new providers and for renewals.

  • By organizing and planning the credentialing process, we can save thousand of dollars of insurance reimbursement denials.
  • Developing a sustainable process will ensure future success.
  • Recognizing key success factors such as completing the CAQH Universal Provider Datasource
  • Determining interim steps for new or missed credentialing.

Credentialing, in general terms, is a verification of your experience, expertise, interest and willingness to provide medical care. In broad terms, credentialing encompasses obtaining hospital or facility privileges, as well as successfully enrolling in health plans as a participating provider. Even after submitting the myriad documents and forms to a variety of third parties to verify your credentials after joining a practice, don’t think that you are done. Even though most facilities and health plans do not require a full re-hashing of the credentialing process, most oblige you to submit annual updates. In other words, credentialing doesn’t stop after the initial forms are submitted. You’ll find that the process consumes hours and hours each year, particularly if you’ve adopted an inefficient process.

Not only does completing forms take longer as the volume of required elements increases, but payers are spending more time to process credentialing paperwork. Unless you are willing to work in a cash-only medical practice and forego all privileges at hospitals and other facilities, there’s not much you can do about the number of credentialing requests or the volume of data requested. What you can do, however, is handle your part of the process more efficiently.

Follow these steps to ensure that you and your staff do not get mired in the credentialing process.

Start early. Don’t expect a swift credentialing process. You need to plan months ahead, especially when a new physician is joining your practice – or you are a newly recruited associate. Indeed, many practices request the elements needed for credentialing at the same time that they send an offer of employment letter to a new physician. Given that it can take many weeks for payers and other organizations to process their own credentialing paperwork, a physician joining your practice who ignores or overlooks your request for this information presents a big financial problem – they cannot bill for their services. Consider tying a new physician’s start date – or initial paycheck – to the successful gathering, submission and signing of key documents. Even if you outsource credentialing, you’ll still need an internal person to doggedly pursue the process – and this person must be persistent to the point of traveling to a physician’s home to get a copy of the medical school diploma off the wall, or escorting the physician to a bank to have a document notarized, if necessary.

Develop a sustainable process. While the initial submission of credentialing forms may leave you exhausted, it’s vital to ensure that there is a workflow that maintains all required forms and documentation because re-credentialing is always just around the corner. Assuming that you do not have the resources to support several full-time credentialing staff, there are three basic options for managing this workflow; which one you select depends on the availability of internal resources – namely, staff and money – or the lack thereof. One option is to formulate a spreadsheet of payers, hospitals and other third parties that require updates, and record the requirements for submissions and deadlines. Assign an employee to monitor the process and empower him or her to take appropriate action to get forms signed and necessary data gathered. Alternately, you can purchase or lease credentialing software, or outsource the process altogether to one of many vendors that specialize in credentialing. Regardless of your choice, be sure to monitor the efficacy and effectiveness of the process so you know you are getting your money’s worth.

Recognize key success factors. Complete the CAQH Universal Provider Datasource®, which is the most widely accepted universal credentialing database. On this form or the many others you’ll find that require completion, avoid the temptation to leave any of the data entry boxes blank. With information missing, that form will eventually be rejected. Because these decisions can take months, you’ll have a lot of catch-up work to do in a very short time. Complete every required element, and attach all requested documentation. Avoid multiple trips to the notary public by paying several staff members to become notaries; it’s a simple process that saves an extraordinary amount of time during the credentialing process. And, never try to estimate dates and other critical data from memory.

Determine what steps to take in the interim. It’s long been a myth that it’s perfectly acceptable to bill under another physicians’ identification as you await the results of the credentialing process. This protocol, however, may lend itself to big legal problems if adverse event occurs – the name listed on the medical claims will not be the actual rendering physician. The protocol of billing under another physician while awaiting a credentialing decision might even be expressly prohibited in your contract with a health plan. One plan commonly endorsed by payers is to use a –Q6 modifier, billing the new physician as a locum tenens. For more information, see the CMS Internet Only Manual 100-04 Chapter 1 Section 30.2.11 The wisest course of action is to learn what the payer requires for credentialing, and follow those instructions precisely.

A useful indicator of a smooth-running credentialing process is the track record of denials and adjustments taken during the billing process related to credentialing. Assuming that you already require your staff to accurately record the reason for each denied or adjusted claim, ask your business office manager to report the total number of claims denied, as well as the number of accounts written off, due to incomplete credentialing.

Credentialing can be a maddening and time-consuming (therefore, costly) administrative process, but you will not be paid until you are fully enrolled and credentialed by your participating health plans. And you can’t expect to attract many patients if you don’t have admitting privileges. In order to keep your office running smoothly, it’s vital to prioritize the credentialing process in your practice.