Why Credentialing is Important for Your Medical Practice

Posted by KUNAL JAIN on Mar 27 2015

Doctor CredentialOne of the many challenges physicians face on top of practicing medicine lies in medical credentialing. There lies a direct connection between provider credentialing and reimbursement of claims and receiving revenue. Without successful credentialing, claims can be delayed, or worse, denied – which is why it’s integral to be aware of deadlines and requests submitted by insurance carriers.

So, What is Credentialing?

Credentialing is a verification process for physicians and medical practices where their qualifications and experience are validated. This is essential if physicians at their medical practice want to become a part of a payer network and provide care and services to patients under a specific health insurance company. Otherwise, patients will have to pay out-of-pocket or choose another office that does use their insurance.

Unless you want to have a practice that is cash-only and has no hospital privileges or access, it would be wise to undergo regular credentialing for existing and new physicians entering the practice. Every provider has different parameters as to the timeline of credentialing—while commercial carriers, such as Aetna, could require every 2-3 years for revalidation, Medicaid may be annually depending on your state, and Medicare’s renewal is 5 years.

Why Credentialing is Important

Credentialing doesn’t just stop with the first submission to your health providers; it is an ongoing process, where they can request resubmission and paperwork at any given time. This is in accordance to state regulations and other accrediting organizations, which have also become stricter to prevent medical fraud with the Affordable Care Act.

There are resources out there such as the Council for Affordable Quality Healthcare (CAQH) Universal Provider Datasource that help with reducing paperwork and are considered the most trusted, but oftentimes the credentialing process can be very time-consuming and cost valuable resources away from other administrative tasks. While you can’t help that the credentialing process may take months to process, the best thing to do is be proactive on your end, and have your paperwork accessible and organized.

Why is this important? If you are not credentialed, you will not be paid by the health plans you are participating in. This is huge. If you don’t respond to the health payers within their allotted time-slot, they may deactivate you as a member and detract any payments or claims. Then, you may have to re-enroll, and that could take months to get your claims back on track from being held or delayed.

This also applies to prospective physicians that may be entering your practice. Make sure once you offer employment to a new physician that you request all of the necessary credentialing paperwork so you can start the process as soon as possible. Otherwise, they will be unable to bill for their services. Delegating someone in your office to oversee these tasks will be extremely important with implementing new physicians and maintaining the workflow of the current physicians and their credentialing necessities.

Whether it’s creating a spreadsheet to keep track of what commercial payers and Medicare requires, or having that employee become a notary, these are all valid strategies to pursue when it comes to credentialing.

This will help your practice maintain revenue and claims, without excess issues and outside influences getting in the way. Here are some examples of paperwork you’ll need to request from physicians, and keep on hand yourself for revalidation purposes:

  • Medical degrees or license(s)

  • Board certificates

  • Malpractice claims history or certificate

  • Social security card

Be prepared for struggles, but know that taking initiative on the credentialing process can save you time on delayed claims and negative problems later (like if a new doctor was scripting under your name, instead of their own, because they were waiting to become credentialed). It’s undoubtedly important to a practice in order to maintain the cycle of revenue and reimbursements.


Topics: credentialing

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