What is Medical Credentialing?
The process through which healthcare organizations evaluate & approve doctors and other practitioners to deliver care inside their networks known as medical credentialing. Credentialing is a crucial safety feature of the healthcare system because it confirms whether a doctor is indeed license to practice. Bellmedex Provide Medical Credentialing Services.
Since insurance companies would only pay claims from licensed physicians, credentialing might also see as the initial stage of the revenue cycle management process.
Typically, a credentialing application needs:
Complete academic records and transcripts
- Extensive work history
- DEA registration, current medical license, and board certification
- Current records of one’s medical history and vaccinations
- Evidence of ongoing malpractice protection
- References, both personal and professional
- Complete explanation of any historical gaps or other oddities
See this NIH article for a more in-depth overview of the background and goals of medical credentialing.
The credentialing procedure may appear overly strict from the doctor’s point of view. Every reference is always checked, every attestation is carefully examine, and every detail of the applicant’s history is confirm from the primary source. In a credentialing application, even a single small mistake or omission might cause significant delays. Given the quantity and variety of parts that make up a credentialing application, mistakes, hold-ups, and logistical challenges may seem all but unavoidable.
DIY credentialing typically involves a sizable Excel document with numerous sheets to keep track of all the various parts and due dates. It will require a lot of time and work.
A careful credentialing provider, however, using modern techniques & technology, fully knowledgeable with the procedure & laws, will make the credentialing process far quicker & simpler.
What Credentialing Services Do
To ensure that the credentialing process goes as smoothly as possible, a credentialing service organizes & maintains credentialing applications for physicians and other stakeholders.
Credentialing services are typically more position than physicians or their staff to address any delays or problems in a timely manner because they have in-depth understanding of the credentialing process and because they are not preoccupied with other activities. Ideally, this implies that the credentialing process takes less time overall, costs less money, and—perhaps most importantly—allows the doctor to start invoicing for services sooner.
Three key areas of services are typically offer by credentialing services to practitioners:
- Assistance for initial credentialing
- Re-certification services
- Administration of “expiable”
Depending on where you are in your practice and career, your own credentialing requirements may change. Credentialing is undoubtedly a crucial step in starting a practice, and if you’re just getting started, you’ll also be submitting your first applications for credentialing. If you have been practicing for a long, maintenance and renewals will constitute the majority of your needs.
Initial Credentialing Services
The initial credentialing procedure will need to be complete by providers who have not yet received credentials from a particular entity. This might happen if you:
- first graduates from college and starts working
- A new state or nation move
- Change jobs Change careers from employment to private practice
- Establish a new practice
- would like to accept new insurance from patients
- After a period of not practicing, resume your practice.
Since several application components must be submit & confirmed for the first time, initial credentialing applications typically entail extra work. The verification of some of these factors, such as your educational background, prior employment history, and personal references, only needs to done once, when you submit your initial application. Primary source verification might extend the timetable by many weeks or months.
Many new healthcare professionals are unaware that obtaining your credentials is a prerequisite for patient care. You may not be able to work, receive payment from insurance companies, or both as a result of delays in the initial credentialing procedure.
Re-Certification Services
Each provider is periodically examine as part of the “re-credentialing” process to make sure they are still certified and able to practice inside a certain network. A “re-credentialing” or credential maintenance service’s goal is to make sure this renewal procedure runs without a hitch. The process of re-credentialing need to be simple from the provider’s standpoint. You can know very little about the re-credentialing procedure, unlike initial credentialing. This is crucial since you will be working and providing care for patients during this procedure, making it highly likely that any problems with re-credentialing may impair your capacity to do so.
A re-credentialing service’s main responsibility is to maintain track of deadlines and make sure that all applications are file well in advance of the due date to give adequate time to address any potential problems. If this not done, the provider risk losing credentials, possibly as a result of a little application fault.
Re-credentialing is frequently simpler because many aspects of the first application, such as education and employment history, remain constant and do not require revision. Many other aspects of a provider’s application, however, are subject to alter and are examine with the same care as during the first credentialing process. These consist of:
- Licenses, certifications, attestations, and other documents that must use by a certain date (sometimes known as “expiable”)
- Work Experience
- Examining any malpractice allegations or other problems
Re-credentialing requires the management of “expiable,” although this is separate from the actual re-credentialing procedure. So, as a separate service, some businesses provide “expiable management.”
Expiable Management Services
Each “expiable” has a unique renewal period, and frequently, in order to account for processing time and any delays, the renewal procedure must started far in advance of the actual expiration date.
The usage of software platforms like expirationreminder.net, Our Records, Smart Sheet, or comparable services is possible in offices that manage expiable internally. An effective Excel spreadsheet can also used.
Regardless of the methods you employ, managing expiable is crucial to making sure that both the re-credentialing process and any new initial credentialing the provider may want proceed successfully. A gap in the validity of any expiable must present in order to prevent automatic loss of credentials and to make the re-credentialing procedure more difficult, sometimes for years.
Hospital Credentialing
A doctor can see patients within a hospital by obtaining credentials from that hospital or hospital system. Hospital staff doctors must deal with credentialing through their employer, and although it is not an easy procedure, staff doctors do have institutional support in this area.
However, with little assistance from the hospital itself, doctors who want affiliate status at a certain hospital must navigate the credentialing procedure on their own. Independent doctors typically need to mention one or more additional medical billing professionals who could treat patients in case of an emergency. These substitute doctors must, of course, already have credentials from that facility. The applicant may use the physician named as a backup as a reference.
Networking and ties to the community play a significant role in obtaining hospital credentials because backup coverage is necessary. New physicians are frequently accept into a hospital or network by established doctors.
In many instances, established physicians inside the network actually oppose outside physicians because they may view them as competitors. For rookie doctors, navigating these connections can be difficult. In such circumstances, a knowledgeable hospital credentialing agency ought to be able to offer you advice.
Internal vs. External Credentialing
That is frequently the best course of action for larger firms. We discover that it usually makes sense to hire a full-time staff person specifically focused on credentialing after a group reaches between 30 and 50 practitioners. Larger group practices and hospital systems may include credentialing departments with numerous full-time employees. The advantage of an internal strategy is having full-time employees who are solely (or at least mostly) concerned with credentialing. This enables personnel to accumulate sufficient expertise to accomplish credentialing dependably & successfully.
