What Is Medical Provider Credentialing for Healthcare Compliance?
Medical provider credentialing in healthcare, also commonly referred to as physician or doctor credentialing, or even more generally as medical credentialing, is the process by which medical practices and healthcare organizations verify the professional and medical credentials of healthcare providers to check the validity and accuracy of licenses and professional certifications.
Typically, the process is most known for credentialing physicians, but similar processes are used to verify nurses and other healthcare providers as well.
Who Requires Provider Credentialing?
Healthcare provider credentialing is a complex and critical part of medical practice operations. Many companies offer contracting and credentialing services but fall short of award-winning results. The simple fact is that physicians and other healthcare providers need proper credentialing through a proven process that verifies education, training, background, skills, and other key qualifications required to properly care for patients and perform encounters. Their livelihood and the viability of the medical practice that employs them depends on these background administrative services to come through in a timely, affordable, and accurate manner.
In addition to needing these services for the medical practice employing them, physicians have to have their credentials and services monitored and evaluated over time by independent third-party organizations to ensure that they are not providing improper care.
Both the healthcare organizations that employ the providers and those that provide the oversight necessary for healthcare insurance companies to provide approved provider lists for insurance companies require a level of high-grade monitoring, reporting, and information checking that makes up the bulk of the provider credentialing and contracting services provides by the Claimocity team.
What is the Credentialing Workload?
The workload that goes into proper provider credentialing is not only bureaucratically complicated and often lengthy, but requires a level of nuanced experience and expertise that can have financial, legal, and operational impacts as any hiccups or issues in the process can cause problematic delays in a providers ability to provide healthcare to patients not to mention generate significant additional costs and legal ramifications for both the provider and medical practice employing the provider.
Healthcare provider credentialing involves many parties and moving parts. Doctors and other healthcare providers — all need to prove they have the education, training, and skills required to properly care for patients. At the same time, healthcare oversight organizations monitor the work of medical providers to evaluate, among other matters, reports of improper care. All of this reporting and monitoring must be continually checked, both by healthcare facilities that employ providers and by health insurance companies that issue approved provider lists.
Certainly, the healthcare provider credentialing process requires significant work. To help clear the confusion, this article details the basics of provider credentialing and offers recommendations on fulfilling the responsibilities as efficiently and effectively as possible.
What is Insurance Credentialing?
Insurance credentialing is the process of verifying a physician’s credentials and professional skills for a health insurance company, commonly referred to as getting on the insurance panels. In order to include a new physician on an in-network provider list, the insurance company has to perform what amounts to a professional background check to ensure that the doctor is qualified and does not have any issues that would preclude them from participating in the payer reimbursement system as an in-network provider.
Other types of relevant credentialing to note are paperless credentialing, which simply refers to the use of electronic or digital software as a replacement for paper forms in order to streamline and expedite the process, and nearly all credentialing and contracting services should be paperless at this point.
Why Bother with Provider Credentials?
Other than wanting to get paid by insurance companies, there is a definite industry need to have some means of oversight on physicians joining organizations and practices to ensure that they are competent and qualified to perform complex and often life changing medical work on patients.
To ensure that there is some systematic level of accountability and compliance to standards, the CMS, which stands for the Centers for Medicare & Medicaid Services, and Joint Commission on Accreditation of Healthcare Organizations both have strict guidelines for the process and require providers to be credentialed and follow their regulations in order for the organization they are affiliated with to be eligible for Medicare or Medicaid reimbursements.
Beyond the CMS and Joint Commission accreditation, there are additional standards that can be applicable and followed to increase the level of compliance including those by the NCQA, AAAHC, and URAC to name a few.
How Does Provider Credentialing Work?
The actual process is very thorough and administratively driven, with thorough follow through and contact with various schools, boards, organizations, and relevant companies and entities to ensure the validity and accuracy of all the provider’s relevant qualifications. There is also a component of a more broad-spectrum analysis of background and issue checks to ensure that there are no red flags that need to be resolved or would indicate issues with competently representing the healthcare organization and treating patients.
The first step is gathering all the relevant information from the provider. When a third party is hired to gather and verify the information, they are often referred to as a CVO or credentials verification organization, and they work with the provider to provide timely and accurate results for the healthcare organization.
The second step is checking everything provided through direct correspondences, software and database searches, verification checks, and other means of acquiring the information necessary to make a thorough decision including finding and ruling in or out any information that could raise questions about whether to credential or reissue credentials for a provider.
The third step is the completion of the process and involves both the healthcare organization employing the provider and the insurance companies listing the provider in their network then awarding the provider with the necessary credentials to see patients, perform their professional duties, and submit for reimbursement at contracted rates within the network.
How Long Does the Credentialing Process Take?
The financial, medical, and legal implications combined with the thoroughness of the process and partial dependence upon slow insurance bureaucracies and relevant entity response times means that the credentialing process can take a long time to complete, commonly ranging from 30-90 days.
Common bottlenecks that can lengthen the process include specific state regulations, graduation confirmation for recent graduates, malpractice suits, red flag issues, and information availability limitations.
The downside of a lengthy provider credentialing process is the significant financial impact that comes from the inability to see patients while waiting for approval. The faster and more efficiently an organization or CVO can generate provider credentialing the better for both the provider and the medical practice hiring him or her.
Not only does the provider lose critical revenue opportunities the longer the process takes but the average loss for a hospital or medical practice is 7k for every day a physician isn’t working. The difference between a 30-day process and a credentialing process that drags out for 3 or 6 months equates to hundreds of thousands of dollars in lost potential.