Everything You Need to Know About Healthcare Provider Credentialing

In the world of healthcare, provider credentialing serves as the essential process where medical organizations verify that healthcare professionals possess the required licenses, certifications, and competencies to deliver quality patient care.

This process also goes by names like physician credentialing, medical credentialing, or doctor credentialing.

While we often associate healthcare credentialing with authorizing physicians, it's worth noting that similar albeit sometimes less exhaustive systems exist for nurses and other healthcare providers.

Alternate Terms for Credentialing

In the healthcare domain, you may come across different terms for credentialing, such as:

Insurance Credentialing:

Informally known as "getting on insurance panels," this process involves health insurance companies verifying a physician's credentials before including them as in-network providers.

Paperless Credentialing:

This term refers to the use of software to streamline credentialing, reducing or eliminating the need for paper-based forms.

Medical Sales Rep Credentialing:

Also called vendor credentialing, this refers to healthcare organizations assessing and monitoring the backgrounds and qualifications of sales representatives and other vendors who require access to their facilities.

Personnel Credentialing:

In this scenario, an organization assigns credentials to its employees or vendors.

Regulatory Bodies and Accreditation

The Centers for Medicare & Medicaid Services (CMS) and the Joint Commission on Accreditation of Healthcare Organizations play pivotal roles in ensuring healthcare providers undergo credentialing.

Non-compliance with CMS regulations can render healthcare organizations ineligible for Medicare or Medicaid reimbursement. Similarly, the Joint Commission accredits organizations that adhere to its standards, a prerequisite for Medicare and Medicaid reimbursement eligibility. States also enforce their own regulations in this regard.

Several other groups set standards for credentialing, prompting many healthcare organizations to adopt these standards to attain additional accreditation. These groups include:

1. -? The National Committee for Quality Assurance(NCQA)
2. -?? Utilization Review Accreditation Commission (URAC)
3. -???The Accreditation Association for Ambulatory Healthcare (AAAHC)
4. -??Det Norske Veritas (DNV)

Understanding Provider Credentialing

Provider credentialing is the process of verifying that medical professionals possess the necessary qualifications to carry out their roles.

This involves reaching out to various organizations, such as medical schools and licensing boards, to confirm the validity of licenses and certificates.

Additionally, credentialing organizations ensure there are no prior reported issues that could raise concerns about a provider's capability to deliver competent patient care.

How Does Provider Credentialing Work?

Provider credentialing unfolds in three primary phases:

1. Gathering Information:

Healthcare facilities or insurance plans request background information from providers, covering their education, licenses, and more. Providers may furnish this information via email, questionnaires, or specialized software. Some organizations opt to collaborate with third-party credential verification organizations (CVOs) to expedite the process.

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2. Information Verification:

In many cases, healthcare facilities or insurance companies take on the responsibility of verifying the provided information.

They directly engage with licensing agencies, medical schools, and other relevant entities to confirm the accuracy of the provider's credentials. Alternatively, credentialing software may be employed to continually cross-check data available online.

Many healthcare organizations employ collaboration and work management platforms to maintain provider records, automatically receiving updates when credentials need renewal or re-verification.

Checks also encompass monitoring reports related to medical incidents, malpractice claims, or other factors influencing provider credentialing decisions.

3. Credential Award:

Once all necessary credentials are verified, healthcare facilities grant providers their credentials.

Similarly, health insurance companies complete their review, deciding whether to approve providers as in-network.

This approval allows providers to receive payment for treating patients covered by the insurer.

Common Information Requested for Credentialing Healthcare Professionals

While specific requirements may vary among healthcare facilities and insurance providers, typical requested information includes:

1. Name
2. - Previous/other names
3. - Gender
4. - Ethnicity
5. - Mailing address
6. - Email address
7. - Daytime phone number
8. - Citizenship information
9. - Recent photograph
10. - Current CV
11. - Date of birth
12. - Social Security number
13. - Education and training
14. - Residency
15. - Licensing
16. - Specialties
17. - Specialty certificates
18. - Qualifications
19. - Career history
20. - Patient age focus
21. - Languages spoken
22. - Hospital affiliations
23. - Medical group affiliation
24. - Practice address
25. - Practice Tax ID Number
26. - Practice phone number
27. - Primary practice contact
28. - National Provider Identifier (NPI) number
29. - Board certification
30. - Acceptance of new patients
31. - Sanctions or disciplinary actions
32. - Malpractice claims history
33. - Proof of professional liability insurance
34. - Continuing medical education documents
35. - Peer references

Credentialing Experts' Insights

Healthcare consultant John, with over a decade of experience in healthcare credentialing, highlights the significance of checking the National Practitioner Data Bank (NPDB) when credentialing providers.

This web-based repository houses data on medical malpractice payments and other adverse actions concerning providers.

Additionally, Mark, with a decade of experience at MD Revenue Group, emphasizes that healthcare facilities may delve deeper into available statistics reflecting a provider's skills, such as mortality rates and patient readmission rates.

He also underscores the importance of peer references in assessing a provider's capabilities and potential issues.

Navigating Credentialing Delays

Credential verification is a time-consuming process, often extending from 30 to 90 days, and occasionally, up to six months or more. Several factors contribute to these delays:

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1. -????????? Differing state credentialing laws and regulations
2. -????????? Graduation confirmation for recent medical school graduates
3. -????????? In-depth investigation of medical malpractice cases

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Moreover, many healthcare organizations continue to rely on paper-based or email applications, further hindering efficiency.

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Addressing the Impact of Lengthy Credentialing

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Extended credentialing timelines can significantly affect healthcare providers and hospitals financially.

Providers cannot treat patients at a hospital until their credentials are established, leading to substantial revenue losses.

In this context, every day a physician remains uncredentialed translates to a significant financial setback, potentially reaching thousands of dollars over several months.

Thus, providers and hospitals must prioritize efficient credentialing processes to mitigate financial consequences.

The Role of the Council for Affordable Quality Healthcare (CAQH)

The Council for Affordable Quality Healthcare (CAQH), a nonprofit organization comprising leading health insurance companies, plays a crucial role in simplifying provider credentialing.

Its online product, ProView (formerly the Universal Provider Datasource), collects standardized information from healthcare providers, including their professional backgrounds.

Hundreds of insurance plans leverage this shared data during the credentialing process, alleviating providers from repeatedly submitting identical information to multiple insurers.

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Pro Tips for Completing CAQH Applications

Experts offer valuable recommendations for completing CAQH applications:

1. Opt for online completion rather than using paper forms to expedite the process.
2. Ensure the provider's resume is precise and complete, adhering to the system's date format requirements and eliminating any time gaps.
3. Keep scanned copies of requisite documents ready for uploading.
4. Promptly re-attest every four months to maintain an accurate provider profile. Failure to do so can lead to delays in credentialing with insurance companies.

Ensuring a Smooth Credentialing Journey

While the credentialing process can be lengthy and intricate for providers and clinic managers, experts offer advice to enhance efficiency. Consider choosing MD Revenue Group for a smoother credentialing journey.