What is Credentialing?
Credentialing is “the process of assessing and confirming the license or certification, education, training, and other qualifications or a licensed or certified healthcare practitioner.”
The process involves organizing and verifying the professional records that qualify a doctor to practice medicine. This includes their board certifications, hospital admitting privileges, education, malpractice insurance, professional references, work history, and more.
This is also applied to facilities, where the facility’s license, accreditation, site reviews, and other factors are evaluated.
What types of credentialing exist?
- Insurance Payers (for contracting with providers)
- Hospitals (for allowing providers to do procedures in their facility)
- Medical Malpractice Insurance (for insuring providers or facilities for commercial and/or general liability insurance)
Who gets credentialed with payers?
- Medical providers: MDs, DPMs, DOs, PAs, NPs, etc.
- Behavioral health providers: psychologists, licensed professional counselors, autism behavior analysts, etc.
- Facilities: Ambulatory Surgical Centers, Community Mental Health outpatient facilities, Physical Therapy Centers, etc.
Why offer credentialing?
Patient Safety is the overall concern of insurance companies or hospitals. Medical credentialing verifies that nurses and doctors are properly trained and certified and have the required professional experience to provide healthcare services to patients. It’s a crucial aspect of maintaining high standards of safety in the medical profession.
Healthcare professionals and facilities will only get paid if properly credentialed with payers: they must also be considered contracted in order to be guaranteed a certain payment. It is possible to get prior authorization for an out-of-network provider, but the payment is still not guaranteed and is often much lower than that of an in-network / contracted provider.
What is contracting?
At any given point during the credentialing process, contracting will take place.
Contracting is when an insurance payer executes an agreement with a healthcare provider or facility in order to guarantee certain rates of reimbursement in exchange for services provided to patients within their network.
If the healthcare provider or facility does not pass through credentialing, then a contract will not be executed.
Without a contract, healthcare providers and facilities will not be paid optimally (or at all in many cases) by insurance companies for claims that are submitted.
How does credentialing happen?
- Lifecycle of an insurance credentialing process:
Provider (either individual or group or facility) or a representative of the provider will initiate the request with the insurance company (payer). - Payer requests information from the provider
- CAQH Proview – this is a website where providers’ credentials are stored. The provider (only individuals) will have a login and keep it up-to-date by attesting quarterly.
- Applications – paper or electronic
- Provider submits applications and required documentation
- Payer reviews the application and completes credentials verifications
- Payer accepts or rejects provider into the network
- Payer executes a contract with the provider and gives the provider an official effective date into the network
- Process takes several months, so one must stay on top of it and avoid delays.
How long does it take?
When can we schedule patients?!
- Credentialing and contracting with payers will take an average of 90-120 days
- Many factors will make that timeline vary, such as:
- Time that it takes for entities to return verifications to the payer’s credentialing verification office (such as a medical school sending a confirmation of a degree to an insurance company)
- Backlog or number of staff within the insurance company
- Pre-requisites being fulfilled before the process can start (such as obtaining Medicare enrollment prior to being able to apply to a Medicare Advantage network)
- A provider being already credentialed, but just transferring to a new group can be faster in some cases than starting from scratch
- Some networks will be closed and you may need to appeal (which takes months if you are even successful)
- When one wants to ask for higher rates/ negotiate a contract offering, that process can add months onto the timeline
- Errors or omissions within an application
- Providers not getting information to their credentialing assistant in a timely way
What do payers need from providers?
What is on a credentialing application?
Applications differ by organization, but here is some Sample Demographic Information that will be on an application:
- Name and Previous names (maiden, non-Anglicized, AKAs) and Degree (MD, DO, DDS, etc.)
- Address, phone and fax number of all office sites
- Office contact person
- Tax ID
- Call group, covering physician, alternate
- Primary and secondary language(s)
- Gender (optional), spouse
- Social security number and DOB
Other items that will be on an application and then verified by a
payer’s credentialing office are:
- Education, including all postgraduate training (internship, residency, fellowship) and dates
- Current and past hospital affiliations from the primary source is an important component of the credentialing process.
- Work history and any gaps in history
- Malpractice insurance history - any claims against the provider are researched and addressed
- Disclosure (sanctions, suspensions, arrests, etc.)
- Board certification, License, DEA and other verifications
- Criminal background checks
- Peer references
- CME credits
- Health history (COVID, Flu shot, TB test, etc.)
- Case Logs in some cases
Re-credentialing
Ongoing process
Re-credentialing is the process of obtaining and evaluating data to support the continued competence of the healthcare practitioner to provide patient care services in or for a healthcare organization.
During the re-credentialing process, the medical staff or insurance company is required to reappraise the individual or facility’s adherence to compliance requirements.
CAQH is a tool the insurances use to extract information for the Re-Credentialing process.
Ask for a raise!
Contract Renegotiation
Providers can ask a payer for an increase in reimbursements.
An insurance company usually requires a provider to fulfill an initial contract (3 years or 1 year depending on the payer) before asking for a raise in payments. They will put the contract on auto-renewal.
Once the initial time period is fulfilled, a provider may send a letter of request to ask for a rate increase.
Many factors will help ensure success, such as:
- Demonstrating to the payer how the provider saves money for the patients and insurance company
- Showing the payer how the provider is unique in their field and why this helps patients in their network
- Proving that expenses are higher than normal for certain procedures that are unique to the provider
- Being highly accessible (i.e.: longer hours, available or extended weekend and holiday hours, location that is accessible to a high population of people with transportation options being abundant)
Why is credentialing so challenging?
Credentialing is a pain point for providers.
- CONFUSING! Insurance companies will often make mistakes, give wrong info, and or leave out important info (such as credentialed but out of network)
- Arduous, time-consuming
- Full-time job staying on top of all of the insurance
- Hard to find the right person to do it
- If not done properly, then collections are drastically lower and unpredictable
“Maker or breaker”
Who does credentialing?
- The office manager – Bad Idea!
- The provider – Bad idea!
- An employee in-house – Expensive and not always a professional
- A professional credentialing company- outsourcing this is a great idea and much lower in cost.
- Stay on top of the credentialing statuses with reporting
- Dedicated team (and not on the back burner)
- Usually, a lower fee than an in-house employee salary
- Has contacts and knows the nuances of the credentialing game.
Foot in the Door for a medical billing account!
How can I use credentialing to obtain a new account?
- Credentialing is commonly a challenge for providers. I
got started in the business because I saw the need. - Offer the credentialing as a service:
- Hire another licensee and get a commission!
- Do not overpromise and take it on without knowing what you are getting into!
- Emphasize the importance of credentialing as the
foundation of optimum reimbursement and it shows your providers you know what you are doing!
Credentialing
How does healthcare credentialing affect medical billers and why does it help with gaining new clients?
