Overview and Tips for Provider Credentialing Process
Provider credentialing is critical for authenticating
expertise, experience, willingness, and interest in providing medical care. If
you are not able to follow the provider credentialing process, it can result in
delay or worse, denial of the provider payment.
Provider Credentialing Process
It is not one of the formalities that you have to
complete or a form that you need to fill. It is an ongoing process that
involves a lot of complexities. Therefore, you need to closely follow all the
requirements. There are many steps that you need to follow in order to qualify
for credentialing. Also, it is essential for your business that you practice
without any hindrances.
Besides the simplistic definition, it also involves
submitting a lot of documents and forms to various third parties for verifying
your practice. You do not need to follow the entire process each year. However,
you must provide annual updates.
Some Tips to Keep in Mind When Credentialing
Here are some tips that you need to consider when going
for provider credentialing.
Do Not Wait
You can mostly complete the process in three months’
time. You should take up to five months to complete the entire process. You can
no more expedite and shorten the process but abide by the regulations and
others’ timelines. The timelines of the payers may vary, so do not wait for
initiating the application process.
Be Careful With Requirements
Most of the applicants lack the critical data for
processing the complete application. Here is what a Credentialing Manager has
to say about the state of applicants’ affairs.
“85 percent of applications are missing critical
information that is required for processing.” Missing, outdated, or incomplete
information is most common in the following four areas:
• Work history and current work status (include the
physician’s effective date with your practice);
• Malpractice insurance;
• Hospital privileges and covering colleagues; and
Furthermore, he also points to the fact that applicants
can avoid the delays by taking care of these small mistakes. Therefore, the
applicants must try to get it right the first time.
Stay Updated on CAQH
CAQH (Council for Affordable Quality Healthcare) has
been running its program for the last 18 years. Most of the providers are
already following this program. Therefore, the new as well as established
physicians, who are adopting this program, have a lot of ease in credentialing
Give a Provider’s Start Date
Many healthcare providers remain reluctant when it
comes to asking new physicians to submit requisite credentialing paperwork. The
health service providers may think of the short-term benefits. Therefore, they
need to focus on complying with the requirements to avoid any delays or worse,
denial of the payments. Furthermore, it is also better for the new physicians
since they can grow their practice a lot faster.
State Regulations Are Important
The reciprocity and other regulations differ from one
state to another. If a physician is credentialed in one state, their
credentialing can be updated in another state. However, if a physician moves
from one practice to another, they do not require any update to the entire
credentialing process. If a physician moves from one state to another and they
are not sure about the details, they need to get in touch with their respective
Medical Group Management Association. This information will help the physician
use the state’s standards to your benefit.
Success Factors to Take Into Account
CAQH Universal Provider has the most comprehensive data
source. It is also accepted across the United States as the most detailed
credentialing database. By filling their form you will be able to find all the
necessary details that you require. However, if you feel tempted to leave some
of these fields blank, you are only increasing your chances of rejection. If
you fail to realize that, it would be months before you are able to know about
the rejection. Once you get the bad news, you would have to provide updates in
a very short time. Therefore, it is better to complete the requirements of all
the requisites. Do not rely on your memory for estimating dates or other vital
clinical data to fill.
Be Careful About the Form Filling Process
Many still believe that it is OK to bill under some
other physician’s name when you are waiting for the credentialing process to
complete. If you tend to fall for this suggestion, you are subjecting yourself
to potentially big legal problems. A lot of the contracts explicitly forbid the
physicians to file under someone else’s name. Health providers must also keep a
check on the total denials so that they can follow a careful course of action accordingly.