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 and 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 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 Missing, outdated, or incomplete information is most common in the following four areas: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
  • Attestations.”

Furthermore, he also points to the fact that applicants can avoid delays by taking care of these small mistakes. Therefore, the applicants must try to get it right the first time.

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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 and re-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 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 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.

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