What do Physician Credentialing Involve?

Hey all, this is Loralee Kapp, the Solutions Manager with Managed Outsourced Solutions. Today I wanna talk to you about physician credentialing and what getting on insurer panels involves.

Physicians and all other healthcare providers need to provide evidence that they have the education, training, and skills needed to provide proper patient care. This information must be continually verified and updated by healthcare organizations that employ providers, physicians setting up a practice, or health insurance companies before issuing an approved provider list. Physician credentialing ensures that providers are contracted by insurance companies in their service area and receive reimbursement for seeing patients in their health plans.

00:43 Role of Physician Credentialing in Medical Billing

For healthcare facilities, physician credentialing is an essential initial step in the medical billing process for many reasons such as –

• Getting physicians on insurer panels
• To treat patients, submit claims, and to be properly reimbursed for services
• Reviewing new providers that are added to the facility
• Expanding their patient base by accepting new patients with specialized insurance plans or
• Ensuring that providers’ credentials are up to date and
• Prevent claims denial and maintain financial viability

Applying for credentialing and maintaining up-to-date information with insurers is a time-consuming and tedious process. That’s the main reason many busy healthcare providers rely on credentialing companies to manage it successfully.

01:27 What Does the Credentialing Process Involve?

Provider credentialing involves collecting and authenticating a physician’s educational qualifications, training, work history, license, regulatory compliance record and other details. Credentialing ensures that providers have the necessary certifications, licenses, and skills to care for patients competently.

The Council for Affordable Quality Healthcare (CAQH) is an electronic solution that simplifies and expedites provider data collection for physician’s credentialing. Typically, healthcare providers create an online profile on this platform and self-report professional and practice information for the enrolment process. Health insurance companies and other healthcare organizations can access CAQH and verify the provider’s credentials.

02:17 CAQH Provider Enrolment and Credentialing Process

The CAQH provider enrolment and credentialing process involves several steps. The first step is creating a complete and up-to-date profile in the CAQH ProView system. The information the profile requires includes:

• Basic personal information
• The practice location, including the practice name and type, the address and contact info, services and certifications, the limitations, the hours, partners, covering colleagues, billing, office manager, and credentialing contact
• Complete, correct current CV
• The education and training history
• Licensing and certificates
• Medical group and hospital affiliations
• Board certifications
• Disclosure and malpractice history
• Malpractice insurance information and
• Work history and references

Major insurance plans use the common set of information on the CAQH to credential healthcare providers. This system allows providers to submit the same information to each insurance company without having to individually upload for each company they would like to credential with.

03:27 New Provider Credentialing

To begin the credentialing process for new provider, new providers must obtain their individual NPI National Provider Identifier number and determine how their services will be billed, based on whether they are individual practitioner or working with an organization.

Before they complete the CAQH application, they should obtain malpractice insurance and register with Medicare in order to treat Medicare patients. Creating a CAQH profile involves registering with the system, completing the application correctly, authorizing participating organizations to access the data profile, and uploading supporting documentation.

Once their CAQH application is complete, they can contact each insurance company they want to be contracted as an in-network provider with and sign up after reviewing their requirements. Once credentialed, providers must re-attest every 4 months to confirm their information in their profile. As insurer rules can change frequently, it’s important to stay updated on the changes.

04:35 Why is Medical Credentialing so Challenging?

Medical provider credentialing is clearly a challenging process:

• It involves a lot of paperwork and procedures
• An incomplete or inaccurate application can delay the process significantly 
• Most insurance payers have their own credentialing process and
• Many payers require re-credentialing every few years and Medicare re-credentialing is required annually in some states
• Insurers have rigorous requirements which can change at short notice

05:07 How an Experienced Insurance Credentialing Service Provider Can Help

Partnering with an experienced insurance credentialing service provider can streamline this challenging process and help you get enrolled with insurer panels without any delay.

Their comprehensive suite of services includes:

• Completing the CAQH application correctly and following up on the status of the application
• Support for re-attestation and recredentialing
• Profile maintenance
• Telehealth credentialing 

Experts can help you get credentialed by government and commercial insurers in your state and maintain your status.

Now that the healthcare system have returned to normal operations, providers need to ensure that their professional and practice information in the CAQH ProView is up to date. This involves logging into CAQH ProView, updating the information and re-attesting to it. This will ensure that every participating plan has the practice’s current information for claims payment and online directories.

A reliable insurance credentialing service provider will ensure that re-attestation is done before the information expires. The support of an expert can go a long way in promoting faster claims processing and reduced denials, and freeing up practice staff from the paperwork so that they can focus on patient care.