Credentialing is the process of establishing the qualifications of licensed medical professionals and assessing their background and legitimacy.

Disclaimer

Physicians and other healthcare practitioners who wish to bill an insurance company and receive reimbursement for services as an in-network provider must undergo a process of credentialing. This process, otherwise known as primary source verification, is the process in which an insurance company verifies the provider’s education, training, experience, and competency. In order to start this process, the provider must submit a credentialing application that details their training and qualifications to treat patients in their area of specialty. Once the verification are completed, the insurance company then decides if the provider meets their internal qualifications to serve as a provider of services to their insured members. After approval of a provider’s credentialing file, the insurance company then issues a participating provider contract that allows the provider of services to bill the insurance company and receive reimbursement as an in-network provider of services. Failure to complete the insurance credentialing process will result in the provider being paid as out-of-network for services rendered

Medical Credentialing is used interchangeably to refer to insurance credentialing or provider enrollment. Medical credentialing includes the primary source verification process at the payer or facility and the insurance contracting. Medical credentialing is utilized by healthcare practitioners when they desire to participate with an insurance company such as United Healthcare or Medicare. The only difference with plans governed by CMS (Medicare & Medicaid) is that the government plans have set fee schedules and therefore do not need to contract directly with the practitioner or practice.

Credentialing Starts the Life cycle of the Revenue

Credentialing is necessary process that needs to be understood and embraced by all practice that wishes for their providers to see patients and get paid. See below credentialing process flow chart.

Five Steps to Easy Physician Credentialing:

Fortunately, there are ways to minimize issues with credentialing. The following five steps are simplistic, yet proven.

Start early:

Though most credentialing can be done within 90 days in many markets, give yourself at least 150 days. As payers have merged and supersized, a practice’s ability to “pull strings” and expedite an application has shrunk. You are working on the timeline of someone else — the payer — and each payer have its own internal timeline for application processing.

Pay attention:

Joellen Scheid, credentialing manager of Anthem for Virginia, says that 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;
Attestations.

Stay current with CAQH:

The Coalition for Affordable Quality Healthcare (CAQH) started its uniform credentialing program about 15 years ago. Most payers in the nation have adopted this program. Physicians and incoming physicians who regularly update and attest with CAQH find credentialing and re-credentialing much easier.

Link a provider’s start date:

This one is a bit controversial — many practices are reluctant to possibly offend a new physician candidate by badgering him to submit the requisite credentialing paperwork. Still, Contracts that link the physician’s start date to the paperwork submission are the ones that are good. For instance, the effective date might be no sooner than 120 days of receipt of such information. It’s better for the practice in the short run: it isn’t scheduling around payers with which the new physician is not credentialed. And it’s better for the new physician, whose schedule can be filled sooner and practice grow faster.

Know your state’s regulations:

Several states have their own laws for timely credentialing, including reciprocity regulations (if a physician is credentialed in another state by Anthem, for instance, her credentialing in your state can be streamlined) and in-state credentialing (a physician moving from one practice to another within the same state does not go through the full credentialing process again). Contact your medical society or state Medical Group Management Association to ensure you are using your state’s standards to your advantage.