Importance of Physician Credentialing Services

Touseef Riaz

August 25, 2022

Physician Credentialing Services

Got a new job? Congratulations! But before you go to start your career, you’ll need to complete physician credentialing. We all can agree on one thing, that even a minor mistake in a medical procedure can cost health, legal and medical expenses. This is why the best physician credentialing services are required. Credentialing process involves hospitals, insurance networks, and healthcare organizations. It includes assessing and confirming the qualifications of the healthcare physicians and checking if they are competent enough for the job or not.

Physician-Credentialing-Services

Why is physician credentialing required?

The physician credentialing process is essential for the healthcare practice as it ensures that physicians are well qualified at their work. Moreover, processing insurance claims also requires proper provider credentialing in healthcare. But the credentialing in medical billing process might differ among healthcare facilities. Following are some of the reasons why the physician credentialing process is critical:

1. It enhances the patient’s trust and satisfaction in the healthcare physician or provider:

Patient’s psychological health plays a significant role in their healing. Moreover, if patients trust their healthcare providers, they are more likely to follow their advice, diet plans, or any lifestyle changes. Not just that, a satisfied patient can more potentially stick with the physician in the long run.

Provider enrollment and credentialing services play a significant role in reassuring the patients that they are receiving the best care. It also helps ensure the patients that the physicians treating them follow high-quality healthcare standards.

2. Lessens the risk of any healthcare errors:

The medical billing and credentialing services ensures that a highly competent physician or medical staff is being hired. Meaning lesser medical errors and, therefore, high standards, quality, and safety of the patient’s health.

3. Proper credentialing prevents the facility from losing revenues:

Physician credentialing ensures that the healthcare practice isn’t losing revenues. To receive reimbursements from the insurance providers, physicians must have proper verifications, i.e., physician credentialing must be done. Insurance providers may reject or deny the medical claim without credentialing, therefore, lesser revenues and reimbursements.

4. Ensures the quality of services:

The top rated credentialing companies ensure that highly qualified medical staff is being hired in the hospital. That they are competent enough to perform the required treatment or procedures. Therefore, ensuring that patients receive quality care, safety, and security.

5. Improves the reputation of the healthcare facility in the industry:

In the era of technology, patients tend to search their physicians online before the treatment. Proper credentialing reflects highly on the physician’s reputation in the healthcare industry, thus the hospitals.

Patients will prefer a healthcare provider with reputable professional experience. This is why medical staff credentialing plays a significant role in patients’ choices.

6. Helps the healthcare organization protect/prevent any potential lawsuits:

Depending on the state, proper credentials are required on the prescriptions by the law.

7. Increases efficiency in the hiring process:

Physician credentialing can be an extremely time-consuming task but is essential. With proper credentialing, the hospital can prevent the admission of any rogue or incompetent medical staff. It increases the efficiency in the hiring process as well as ensures safety and trust among the patients. 

What is credentialing and its purpose?

The physician credentialing services prevent the hiring/admission of any underqualified or rogue physicians or medical staff. Therefore, ensuring high-quality care and safety of the patients. This process involves verifying the competency of the physicians demonstrated by their qualifications, including:

  • Academics or education
  • Professional experience
  • Certifications
  • Training
  • Licensing

Physician credentialing ensures that the applicant is:

  • Who they say they are
  • Are not in violation of any law
  • Have a current license
  • Fully competent for the job applied

Physician Credentialing Process:

The steps of the physician credentialing services differ according to the healthcare organization. But there are some similar major components that each physician is inclined to fulfill. Following are the standard/similar steps of the proper physician credentialing process.

1. Start early:

Hiring a new physician? Give yourself enough time to properly check the healthcare provider’s entire background. If you rush the credentialing process of the incoming physician, it may lead to errors and mistakes, costing your practice a fortune. One of the most asked questions is; how long does the complete credentialing process take?

A standard credentialing process can be of 90 to 120 days. Now there can be several complexities in the process, which is why hiring experts to carry out the process is beneficial. Credentialing process ensures that all the correct documents and credentials are available along with current and valid licenses. Physician credentialing specialists should be well-informed regarding the standards and regulations of the process. Starting early in credentialing gives you enough time to:

Thoroughly assess each physician

– Check-in and work with the insurers to review the credentials of your physicians.

2. Pay close attention to the physician’s applications:

Usually, most of the critical information is missing from the physicians’ credentials. Thus, delaying the entire credentialing process or even leading to claim denials. For this reason, the specialists looking over the process must know what documents are required for credentialing. The specialists must ensure/verify proper information is present in the physician’s applications.

What documents are required for physician credentialing?

Common documents/information required for physician credentialing may include (but are not limited to):

  • Name
  • Social security number
  • Demographic information
  • Education information
  • Residency details
  • Career history
  • Proof of licensure
  • Gender
  • Citizenship, language, and ethnicity
  • Specialties and patient focus
  • Claim history
  • Proof of insurance

Note that every insurer requires a different set of documents or forms; therefore, knowing and submitting the correct documents is essential.

According to AAPC:

Some of the basic requirements/information required include:

The education, training, and board eligibility or certification

The work and medical staff history

The clinical privilege history

Names and emails of peers who can provide the reference

Clinical report cards and performance reviews

The malpractice insurance carriers and any claims history

Explanations for any gaps of 30 days or more in education, training, or work history

Federal, state, and professional licenses and registrations

3. CAQH Enrolment:

Staying current and active with the Council for Affordable Quality Healthcare (CAQH) is essential for the physician. Various major insurance payers require partner facilities’ credentialing to be applied through CAQH. This program has been adopted by various insurers. Moreover, it makes the entire physician credentialing services way easier & faster.

4. Know your State’s and Federal Regulations:

Physician credentialing is a frustrating and time-consuming process. And after doing all the hard work, finding out that the physician is already credentialed in another state can add to it. All that work, effort, and wait only to find out they are registered in another state! This is the reason why one should know the regulations of their state as well as the federal laws. Every state has its own laws and regulations that may even work to your advantage.

5. Prioritize the right insurers:

Physician credentialing is an essential process in medical billing. There are various insurance carriers out there, and this is why prioritize what payers to submit the applications first. For starters, how about submitting the physicians’ credentials first to the insurers with most of your patients? In this way, your medical billing won’t be affected that much.

Secondly, being familiar with the insurer’s regulations is also essential for faster approvals. Thirdly, some insurers also provide an abbreviated application for physicians already credentialed in-state. So, start by making the list of insurers and document the applications according to them.

6. Verification:

When the required documents are submitted, the process of verification begins. Now it can be done manually (the old-fashioned way), via credentialing software, or by hiring a third-party top-rated credentialing company. 

Verification involves checking whether the physician is who they demonstrate via their credentials. Manual verification consists in calling or emailing the med-schools and other key organizations to verify the information in the application.

Other methods involve the use of credentialing software, automating the entire process. On the other hand, the whole physician credentialing services can also be outsourced to a third party like U Control Billing. In this way, you can achieve the following:

 Lesser human resources required

Less expensive

Improved efficiency

Lesser workload and paperwork

Increased security

Faster turnaround

Medical Credentialing Services at U Control Billing include:

Credentialing specializing in all the states

Data Gathering & CAQH Enrollment

 Application Submission & Payer Communication

 Medicare Revalidations & Yearly Maintenance

Re-Credentialing and Demographic Updates

The in-house or third-party company should take the time to thoroughly check the credentials of all the physicians joining the practice. These documents include:

Education

Professional background

State licenses

Immunization records

References

Recredentialing:

Recredentialing is periodic credentialing (reviewing and verifying) the physicians’ credentials. Most providers are required to complete the re-credentialing process after every three years (36 months).

Error in Physician Credentialing;

Physician credentialing is a tedious task, and errors in the process can lead to serious complications and liabilities. Mistakes in credentialing can cost the healthcare practice money (fines), reimbursements, and revenues. Some of the most common errors in medical credentialing include:

Relying on limited administrative staff to handle several healthcare physicians and medical staff credentialing.

Incomplete physician applications

Physicians are allowed to treat patients before completing the credentialing process.

Not updating and verifying the updated licenses or certification information

Incomplete/missing primary source of verification

Errors while entering the data.

Outsourcing Physician Credentialing Services:

As discussed earlier, credentialing is an essential process for the healthcare practice, its revenues, and the patients. Before hiring a third party, look for their industry’s medical credentialing services reviews and reputation. Third-party companies like U Control Billing can manage your credentialing process while you can focus on your patients. 

 By outsourcing credentialing services to U Control Billing, you get:

  • Affordable pricing, i.e., lesser physician credentialing services cost
  • Faster turnarounds
  • Software flexible 
  • Increased cash flow

Frequently Asked Questions (FAQs) 

1. How often does a provider need to be credentialed?

Most providers are required to complete the re-credentialing process after every three years (36 months). However, some healthcare providers might perform the re-credentialing process sooner than that. Recredentialing is periodic credentialing (reviewing and verifying) the physicians’ credentials.

2. What does it mean to be a credentialed provider?

The physician credentialing process is essential for the healthcare practice as it ensures that physicians are well qualified at their work. This process involves verifying the credentials of the physicians, their professional background as well as their competency.

3. How long is the credentialing process?

A standard credentialing process can be of 90 to 120 days. Now there can be several complexities in the process which is why it can take 90 days or even 120 days to complete. Therefore, hiring experts to carry out the process can be quite beneficial.

4. Which states need credentialing services for physicians?

Credentialing process might differ among healthcare facilities but is required to ensure proper reimbursements and quality of care. The physician credentialing services prevent the hiring/admission of any underqualified or rogue physicians or medical staff. This process involves verifying the competency of the physicians demonstrated by their qualifications.

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