7 Essential Steps in Provider Credentialing

In healthcare, guaranteeing the competency of providers is essential. Credentialing stands at the core of this effort, meticulously confirming a physician's eligibility to practice in their respective fields. Credentialing outlook expands beyond the verification of licenses and certifications; insurance companies scrutinize a physician's educational background, affiliations, training records and most importantly, malpractice claims or adverse incidents. This thorough vetting process aims to eliminate potential risks of fraud, ensuring patient safety and upholding standards of care. However, it is crucial to recognize that credentialing offers only a snapshot of a provider's qualifications at a given point in time. Continuous monitoring is necessary to ensure ongoing adherence to professional standards. This continuous monitoring is being taken care of by advanced credentialing software and services.  

This blog delves into the seven crucial steps of provider credentialing, offering guidance for a seamless and effective process.

Important Steps in Provider Credentialing

Provider credentialing involves several important steps to ensure that the healthcare professionals are well-qualified and meet the standards for safe and effective care. Seven essential steps typically include:‍

Identifying and Gathering Required Documents

This involves collecting a comprehensive set of documents and information from the provider that demonstrate their qualifications and experience including:
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• Education verification: diplomas, transcripts and degrees earned.
• Training verification: certificates of completion for any relevant training programs.
• Professional licenses: active and valid licenses to practice medicine in the relevant jurisdiction.
• Board certifications: current board certifications relevant to the provider's specialty.
• Work history verification: employment records from previous healthcare positions.
• Professional references: contact information for references who can speak to the provider's skills and experience.
• Malpractice history: information about any past malpractice claims or lawsuits.
• Other relevant documents: This may include memberships in professional organizations, awards or recognitions received, and publications authored by the provider.

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Scrutinizing Information

Before submitting a provider credentialing application, ensuring accuracy and completeness is essential. Information and documents collected by providers are validated through different available portals. State licensing, DEA licensing, and board certifications portals are available for this purpose. Incomplete and incorrect information can cause delay in processing which may lead to billing denials and administrative errors, causing a negative impact on RCM.

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Primary Source Verification

Both third party healthcare administrators and insurance companies verify the accuracy of the information provided in the application directly from the primary sources, such as Office of Inspector General (OIG), SAMS, Preclusion Lists published by the relevant authority of the state, and previous employers. By directly contacting these primary sources, they can obtain reliable and up-to-date information about the healthcare provider. This thorough verification process helps mitigate the risk of credentialing errors or discrepancies and ensures that only qualified and competent providers are granted privileges/approval to deliver patient care within healthcare facilities or networks.

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Leveraging CAQH to Streamline Credentialing

CAQH provides a Universal Provider Application (UPA) that simplifies credentialing. This single, standardized portal allows providers to submit their information electronically, saving time and effort. By offering a centralized platform, CAQH streamlines the credentialing process, by reducing administrative burdens and eliminating duplicate data entry across insurers. Completing the CAQH application electronically is faster than manual paper-based submissions, allowing providers to input information once and share it with multiple insurers without the need for separate forms.

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Verification and Review

Once applications are submitted, the verification process begins. Insurers will contact primary sources to confirm details like education, malpractice and licensure.  Although the credentialing process typically lasts around 90 days, it might get stretched up to 120 days.

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Following Up: Proactive Communication

Rather than passively waiting for two to three months to hear back from insurers during the credentialing process, proactive follow-ups can expedite the application processing and subsequent approval. Here are some effective strategies:

• Build relationships with key contacts within the insurance company, such as leadership and executive assistants, to facilitate the progress of your application.
• Opt for phone check-ins over emails to increase the likelihood of receiving a prompt response.
• If additional information is requested, promptly gather and verify all required documents to prevent unnecessary delays.
• Establish clear communication channels between providers, credentialing staff, and insurers to avoid misunderstandings and delays.

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Beyond Credentialing: Recredentialing and Ongoing Monitoring

Once a healthcare provider’s credentialing is approved by the insurance, it is crucial to understand that this is not a permanent status. Credentialing is a continuous process that requires constant attention.

If any errors in  provider's information are identified, insurers must be promptly communicated. Failing to rectify inaccuracies before insurers notice them independently could lead to credential revocation.

Typically, providers require re-credentialing every two- three years. While a credentialing software can aid in managing this process and alert you to upcoming renewals, insurers should also send notifications after the three-year period. Responding promptly ensures uninterrupted patient care provision by your providers.

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Additional Considerations to

• Technology Solutions: Credentialing software can streamline document management, track application progress, and automate tasks, thus improving efficiency and reducing the costs associated with it. 
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• Digital resumes: Digital resumes offer healthcare providers a flexible way to showcase their qualifications, facilitating quick and easy sharing with credentialing professionals, hospitals, or healthcare organizations. The ability to update in real-time allows for constant accuracy without the hassle of reprints or resubmissions.
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• Calendar Notifications: Calendar notifications help healthcare providers stay on top of license renewals, continuing education deadlines, and other credential-related tasks, reducing the risk of lapses. Automated alerts allow providers to focus on work without missing important deadlines, ensuring compliance with regulatory requirements.

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Conclusion:

By following these steps meticulously, healthcare organizations can ensure that their providers are competent, qualified, and capable of delivering high-quality care to patients while maintaining regulatory compliance and patient safety standards. Effective provider credentialing not only protects patients but also enhances the reputation and credibility of healthcare facilities and providers in the industry. It should, thus, be done with precision and discipline leaving no scope of errors and delays in the process. 

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If you are a healthcare provider and wish to discuss the important steps in provider credentialing, feel free to write to us at partnerships@homrcm.com.

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