Physician Credentialing – What Getting on Insurer Panels Involves

by | Last updated Mar 4, 2023 | Published on Aug 19, 2022 | Insurance Credentialing

Physician Credentialing
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Physicians and all other healthcare providers need to provide evidence that they have the education, training, and skills required to provide proper patient care. This information must be continually reported and checked by healthcare organizations that employ providers, physicians setting up a practice, and health insurance companies before issuing an approved provider list. Physician credentialing ensures that providers are contracted by insurance companies in their service area and receive reimbursement for seeing patients in their health plans.

For healthcare facilities, physician credentialing is an essential initial step in medical billing for many reasons:

  • Getting physicians on insurer panels
  • To treat patients, submit claims, and get paid properly for services
  • Reviewing new providers added to the facility
  • Expanding their patient base by accepting new patients with specialized insurance plans
  • Ensuring that providers’ credentials are up to date
  • Prevent claims denial and maintain financial viability

Applying for credentialing and maintaining up-to-date information with insurers is a time-consuming and tedious process. That’s why busy healthcare providers rely on credentialing companies to manage it successfully.

What Does the Credentialing Process Involve?

Provider credentialing involves collecting and authenticating a physician’s educational qualifications, training, work history, license, regulatory compliance record and other details. Credentialing ensures that providers have the necessary certifications, licenses, and skills to care for patients competently.

The Council for Affordable Quality Healthcare (CAQH) is an electronic solution that simplifies and expedites provider data collection for physician credentialing. Typically, healthcare providers create an online profile on this platform and self-report professional and practice information for the enrolment process. Health insurance companies and other healthcare organizations can access CAQH and verify a provider’s credentials.

The CAQH provider enrolment and credentialing process involves several steps. The first step is creating a complete and up-to-date profile in the CAQH ProView system. The information the profile requires typically includes:

  • Basic personal information
  • Practice location information, including the practice name and type, address, contact information, services, certifications, limitations, hours, partners, covering colleagues, billing, office manager, and credentialing contact
  • Complete, correct current CV
  • Education and training history
  • Licensing and certificates
  • Medical group and hospital affiliations
  • Board certifications
  • Disclosure and malpractice history
  • Malpractice insurance information
  • Work history and references

Major insurance plans use this common set of information on CAQH to credential healthcare providers. With this system, providers don’t have to submit the same information to every insurance company they may want to enroll with.

New Provider Credentialing
To begin the credentialing process, new providers should obtain their individual National Provider Identifier (NPI) number and determine how their services will be billed, based on whether they are individual practitioners or working with an organization.

Before they complete the CAQH application, they should obtain malpractice insurance and register with Medicare to be able to treat Medicare patients. Creating a CAQH profile involves registering with the system, completing the application correctly, authorizing participating organizations to access the data profile, and uploading supporting documentation.

Once their CAQH application is complete, they can contact each insurance company they want to be in-network with and sign up after reviewing their requirements. After getting credentialed, providers must re-attest every 4 months to confirm their information in their profile. As insurer rules can change frequently, it’s also important to stay updated about changes.

Role of Medical Credentialing Services

Medical provider credentialing is clearly a challenging process:

  • It involves a lot of paperwork and procedures
  • An incomplete or incorrect application can delay the process significantly
  • Most insurance payers have their own credentialing process
  • Many payers require re-credentialing every few years and Medicare re-credentialing is required annually in some states
  • Insurers have rigorous requirements which can change at short notice

Partnering with an experienced insurance credentialing service provider and streamline this challenging process and help you get enrolled on insurer panels without any delay.

Their comprehensive suite of services includes:

  • Completing the CAQH application correctly and follow-up on the status of the application
  • Support for re-attestation and recredentialing
  • Profile maintenance
  • Telehealth credentialing

Experts can help you get credentialed by government and commercial insurers in your state and maintain your status.
Now that the healthcare system has returned to normal operations, providers need to ensure that their professional and practice information in CAQH ProView is up to date. This involves logging into CAQH ProView, updating the information and re-attesting it. This will ensure that every participating plan has current information for claims payment and online directories.

A reliable insurance credentialing service provider will ensure that re-attestation is done before the information expires. The support of an expert can go a long way in promoting faster claims processing and reduced denials, and freeing up practice staff from paperwork so that they can focus on patient care.

Loralee Kapp

Since joining our RCM Division in October 2021, Loralee, who is HIT Certified (Health Information Technology/Health Information Management), brings her extensive expertise in medical coding and Health Information Management practices to OSI.

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