Medical Credentialing & Enrollment Services

In healthcare, Physician Credentialing is the procedure of organizing and verifying a doctor’s professional records. It includes their board certifications, hospital admitting privileges, education, insurance, professional references, work history, and more. It’s a vital safeguard for patient safety and risk management.

The point of physician credentialing is to verify the accuracy of the information the doctor has included on their application. For some information, the practice, hospital or credentialing provider will perform Primary Source Verification – for instance, contacting the medical school to verify that the doctor did indeed attend the school and graduate with the stated medical degree.

Why does a Physician need Credentialing Services?

Actually, physicians can do this themselves – but a professional physician credentialing service would remove all the hassles from the equation. You can easily spend more time doing something you love while a professional credentialing service for physicians like Stars Pro do all the hard work for you.

5 Steps for Physician Credentialing

Physician credentialing is essential to receive in-depth network reimbursement from insurance plans.  Procrastination and haphazard processing can spell cash-flow disasters for your new provider.  Fortunately, there are ways to minimize issues with credentialing. Here are five simplistic, yet verified, techniques to improve your credentialing success.

1. Start early

Be aware that most commercial insurance credentialing and contracting will take 90 – 120 days on average.  Some plans are even slower, so don’t wait until the last minute.  Many new practices or practices hiring a new provider make the mistake of beginning the process a month prior to a desired start date and then become frustrated when they cannot receive in-network reimbursement for another 3-4 months until the network contract process is complete.  You must go through two processes with each insurance company. The credentialing process where they verify all your education and training and then present your file to the credentialing committee for approval. The approval/rejection is based on their internal credentialing requirements.  This first step typically takes around 90 days, second is the contracting process.  The contracting process is where you are given the network contract for evaluation and execution.  Only after your network contract is put into effect can you bill a commercial insurance company and receive in-network reimbursement.  Commercial plan contracts do not have any retroactive billing provisions, so you will only be able to receive full reimbursement after your effective date.

2. Pay attention to the details

With such a lengthy process ahead of you, don’t delay your implementation by submitting credentialing applications with missing or incomplete information.  Here are some of the most common errors found on payer enrollment applications.

  • Incomplete work history – you must include your current practice and all prior professional work history since graduating medical school and your history must include mm/yyyy format on all start/end dates.
  • Malpractice insurance – you must include your current policy and up to 10 years policy history.
  • Hospital privileges – you must have admitting privileges to an in-network hospital in order to participate with a health plan.  If you do not, then you will need to have an admitting arrangement in writing with another in-network physician who will attest to an agreement to admit any of your patients that require in-patient services.
  • Covering colleagues – you are responsible for providing coverage for patients 24/7 and will need to disclose colleagues who cover for you when you are away.  This is particularly important for solo practitioners.

    Attestations – fully answer all yes/no questions on each application and provide complete details for response when necessary.Getting your applications correct the first time will minimize the time delays for your new provider.

3. Stay current with CAQH

A current CAQH profile is an important part of commercial insurance credentialing.  Make certain that your CAQH profile contains all personal details, attestations, signature pages, and required documents.  A majority of commercial payers utilize CAQH to retrieve the bulk of credentialing information.  An incomplete profile will cause a delay in the process.

4. Require involvement from your new provider

When you hire a new provider, make sure he or she knows they are responsible for completing the credentialing process for all the payers with which your organization participates.  Don’t think it is an inconvenience or offensive to a new provider to require them to complete necessary credentialing documents; it is their absolute responsibility. 

In order for the practice to be paid for their professional services, they must go through the credentialing and contracting process with each payer.  The best practice would be to link a provider start date to completing primary payer credentialing.  Build-in corrective measures to employment contracts if a provider is uncooperative with credentialing.

5. Know your key payers

Know which payers represent 80% of your business so that you can prioritize credentialing to complete those payer processes first.  You can selectively schedule patients for your new provider based on which plans have been completed until the new provider is fully credentialed.

Credentialing is a dreary process.  If you are not fully prepared with all vital information to complete the process on first compliance, you will cause delays in the process.  It is the best strategy to only begin the process with payers after you have assembled all information typically required during the payer credentialing process.

FAQS ABOUT CREDENTIALING

Q: Why we would want credentialing?

A: Being credentialed with insurance panels means that you are able to see patients who have specific insurance plans and bill those insurance companies for the services you provide. This can extensively improve the number of clients who can access your services.

Q: Do I get to choose the panels I want to be on?

A: Yes. When you sign up for credentialing with us, you get to choose exactly which panels you want and don’t want, to be credentialed with.

Q: What if I don’t know which panels in my area are best for me?

A: We can help! One of our credentialing specialists will talk with you by phone and can help you to select the panels in your area that will be the best fit for you and your practice.

Q: How long does the credentialing process take?

A: The credentialing process generally takes between 90-120 days. When you sign up for credentialing with us, we will complete your credentialing application and start submitting it to insurance companies. We then follow up regularly with insurance companies to make sure that your credentialing applications are processed and approved as soon as possible.

Q: Do you have experienced credentialing providers in my area?

A: You bet! We have credentialed literally thousands of providers across the United States. No matter where your practice is, we have the experience to get you enrolled.

Q: Do you have experienced credentialing providers in my specialty?

A: We have credentialed healthcare providers of more types than we can list: from chiropractors to behavioral health providers, to surgeons. If you are eligible to be credentialed, we can get you credentialed!

Q: Am I guaranteed to get on the panels I choose?

A: If you are fully licensed, we should have no problem identifying plenty of insurance companies and third-party payers for you to be credentialed with. In some areas, some panels can be very selective or closed. In these instances, we will talk with you about the likelihood of a successful credentialing process. We want you to get the most out of your credentialing investment!

Q: What if the insurance panel I want to be credentialed with is closed?

A: Finding a closed panel can be baffling. However, sometimes when panels say they are closed, they are still accepting providers, but on a limited basis. In the case of a panel saying that they are closed, we can still submit an appeal to the insurance company on your behalf. During an appeal, we will try to connect with the insurance company representative assigned to your area. We will then stress important parts of your qualifications and clinical practice. For instance, perhaps you have a specialty that the insurance company desires, or you are practicing in a neighborhood that is underserved. We do have success with many of our appeals. However, if a company is saying that their panel is closed, it might not be possible to get on the panel at that time.

Q: What is the credentialing process for nurse practitioners?

A: The nurse practitioner’s credentialing process involves the verification of education, licensure, certification, and reference checks. In order for a nurse practitioners to be eligible to bill government agencies and other commercial insurance companies, they must be credentialed. Initial credentialing involves a lot of paperwork.

© Stars Pro® 2021 | All Rights Reserved