The Process of Provider Credentialing Consists of Many Moving Parts

The process of Provider Credentialing consists of many moving parts

The primary purpose of provider credentialing is to ensure that healthcare providers have the required training and experience to provide the highest level of care to patients. But often undertaking the entire process in-house can be high-risk and overwhelming to staff. What can providers do to improve verification and validation of professional’s qualifications? 

Understanding the process – Five key steps of the provider credentialing process 

When your facility hires a new healthcare provider, it’s pivotal to move them through the medical credentialing process. Even if a healthcare provider has been approved by payors in the past, they need to reapply each time they begin work with a new employer. How can you make sure to execute provider credentialing efficiently? 

Step 1: Identify the required documents 

Before you start, it is important to note that each insurer requires different documentation and even a single piece of missing information can set the process back by weeks or months.  

The list of documents required normally include: 

  • Name 
  • Social security number 
  • Demographic information (ethnicity, gender, citizenship, languages spoken) 
  • Education and residency information 
  • Proof of licensure 
  • Career history 
  • Specialties and patient focus 
  • Claim history 
  • Proof of insurance 
  • Information about your healthcare facility 

While most of this information is generally available from the provider’s resume, your practice must take steps needed to ensure accuracy for provider credentialing.  

Step 2: Check for accuracy by primary source verification 

  • Conduct a meticulous background check 
  • Verify educational history, licensing, board certification, and reputation through healthcare organizations such as: The American Medical Association (AMA), The Educational Commission for Foreign Medical Graduates Certification (ECFMG), The American Board of Medical Specialties 
  • Review history of credentialing, privileges, and insurance claims 

Step 3: Completing the CAQH 

Several healthcare insurers require practices to apply for credentialing through the Council for Affordable Quality Healthcare (CAQH) parallel to completing their individual applications. 

  • Once your facility has filed an application with an individual insurer, they’ll provide a CAQH number and an invitation to apply. 
  • CAQH approval can be significantly delayed by any inaccurate or incomplete information. 
  • After submitting the initial application, be prepared to re-attest; you’ll need to attest that a provider’s information is correct four times each year to maintain the eligibility.  

Step 4: Wait for the verification 

Now that you have completed all the necessary steps, you’ll need to wait for approval. Ideally this should take 90 to 150 days though sometimes it can be as long as 6 months. Susan Ward, the director of payor enrollment at Simply, explains that the process becomes complicated in part because each state has specific provider credentialing laws and regulations.   

Step 5: Recertification  

The provider credentialing process is an ongoing one and does not end with approval, meaning continuous work for the staff at your practice. 

  • If you notice an error in an employee’s documentation, it’s mandatory to notify insurers promptly. If they notice the error before you submit a correction, it could be grounds for revocation. 
  • Most providers will need re-credentialing every three years. 

The downsides of handling provider credentialing in-house  

Provider credentialing is one of the most significant compliance issues due to its prominent impact on revenue and credibility, along with the myriad steps associated with the process. Doing it in-house requires extensive time and attention. The slightest lapse could result in problems at multiple levels. Here are some of the most common problems faced by practices that are trying to juggle the precarious task of credentialing. 

  1. Finding and retaining qualified staff. 

It is becoming increasingly challenging to identify, retain, and train qualified staff to complete initial and continuous credentialing. Provider credentialing is one of the most labor-intensive areas in the healthcare industry and is the most important step to any organization’s success. 

  1. Handling a staggering amount of data while ensuring that there are no errors. 

A major challenge is collecting, assessing, and maintaining a huge volume of data. Organizations that continue to manually process their data can have up to an 85% error rate due to human errors and oversights. Seemingly trivial information such as dates, names, and locations can be incorrect or missing, leading to delays in processing and payments. 

  1. Struggling to speed up the process for the purpose of revenue generation. 

The efficacy of the process depends on various contingencies such as accuracy and timing, resulting in inevitable delays in payment. When done manually the process is even more drawn out and leads to interruptions in revenue. This in turn is detrimental to the financial health of your practice.  

  1. Compliance issues 

Practices that are unable to keep up with ever-changing compliance requirements are vulnerable to unexpected fines and penalties. Since provider credentialing is not a one-time process that can be forgotten after approval, it demands the constant attention of an individual focused solely on it.  

  1. Privacy and security  

Organizations must make sure that all information regarding prospective candidates and applicants is private, confidential, and secure. If information is leaked, the organization can be subject to hefty fines and sanctions.  Outsourcing this process can simplify the process and leave you more secure. 

How EMPClaims can simplify the process for you 

Here is what you can expect from your partnership with us. 

  • Reduced workload 
  • Reduced risk 
  • Reduced labor cost 
  • Timely payments and reduction in delayed revenue (associated with credentialing 
  • Less burden on your staff 
  • Protection against fines and penalties to safeguard your practice 
  • Minimizing risk of turnover 
  • Overall increased efficiency 

Reach out to our team to learn about our provider credentialing services.

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