What Is Credentialing in Medical Billing?

by | Last updated Mar 4, 2023 | Published on Aug 23, 2022 | Insurance Credentialing

Credentialing in Medical Billing
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Also referred to as physician credentialing, healthcare credentialing or insurance credentialing, credentialing is the process of obtaining, verifying, and assessing the qualifications of a medical practitioner to ensure he/she will be able to provide the required medical services. Credentials are documented evidence of licensure, education, training, experience, or other qualifications of the medical practitioner. Credentialing is a mandatory process in medical billing. Getting credentialed allows healthcare providers to become enlisted with the insurance companies they prefer to contract with. Credentialing helps ensure that physicians can provide the right care to their patients.  Payers also use this credentialing information to determine if physicians have the necessary professional experience to provide healthcare services to their beneficiaries.  Most health insurance companies including CMS/Medicare, Medicaid, and Commercial plans require this process, as proper credentialing helps to maintain high standards of safety in the medical profession.

Credentialing with insurance companies is critical for practices and providers to

  • improve confidence in patients
  • establish professionalism in a healthcare setting
  • get reimbursed on time without delays
  • reduce the medical errors and provide quality treatments
  • grow the patient base
  • accept new patients with specialized insurance plans

Customized insurance credentialing and enrollment services are crucial for physicians when starting a new practice or joining a new one, switching from one physician practice group to another, becoming affiliated to new groups or practices, and enrolling with new payers.

When hiring a new physician, nurse practitioner, or another healthcare provider, it’s also essential for practices to move them through the medical credentialing process. Healthcare facilities need to ensure their healthcare providers have proper credentials in order to process insurance claims. Medical credentialing verifies that nurses and doctors are properly trained and certified and have the required professional experience to provide healthcare services to patients.

Once the provider is done with credentialing, patients can utilize their insurance cards to pay for the medical services consumed and the provider will get reimbursed by the concerned insurer for the medical services provided. Healthcare providers work to get enrolled and credentialed with maximum number of payers, which increases the number of patient referrals. However, credentialing and provider enrollment are not the same. While credentialing is the validation of a provider in a health plan and the approval to join the network, provider enrollment is the process of requesting participation in a health insurance network as a provider.

Key Steps Involved in the Credentialing Process

Insurance credentialing process validates that a physician meets the standards for delivering clinical care, wherein the Payer verifies the physician’s education, license, experience, certifications, affiliations, malpractice, any adverse clinical occurrences, and training. This process is mandatory for the providers or nursing staff to be in network with certain insurance companies and get paid for the services provided to their patients who are using that Insurance plan.

The process involves these key steps –

Identify relevant documents

Each insurer requires different documentation and forms. To submit the application, the provider has to include all the documentation the insurers have asked for and missing even a single piece of information can delay approval by weeks or months. Details required mainly include name, SSN or Social security number, demographic details, education information, proof of licensure, claims history, career history and more.

Submit application forms

Once the relevant details are available, the next step is to prioritize insurers by making a list of all insurance providers the practice is planning to file with. Recheck and verify all the documents collected and complete application forms either online or paper. Any errors such as incorrect phone numbers or wrong month or date of employment in the submitted information can cause issues.

Complete the CAQH profile

Several major healthcare insurers require partner facilities to apply for credentialing through the Council for Affordable Quality Healthcare (while also completing their individual applications). Providers must complete the CAQH form on paper or online. After submitting the initial application, make sure to re-attest the information when required.

Regular Follow-ups

Provide clarifications to questions from payers and follow-up on submitted credentialing requests and ensure that the application will be approved without unnecessary delays. The physician credentialing process is time-consuming and may generally take between 90-120 days.

Re-credentialing

Re-credentialing is periodically reviewing and verifying the professional credentials in conjunction with payers’ credentialing criteria. The re-credentialing process may include application review, Credentials verification, and Regional Network and Credentialing Committee (RNCC) review.

As insurance credentialing is a time-consuming and expensive process that can consume much of any practice’s resources, a practical solution is to outsource this requirement to expert providers. Each state has its own credentialing requirements. Understanding and closely following these requirements can help reduce your practice’s liability in the face of potential malpractice claims. Professional credentialing companies can assist with provider enrollment and credentialing support for practices in all medical specialties.

Julie Clements

Julie Clements, OSI’s Vice President of Operations, brings a diverse background in healthcare staffing and a robust six-year tenure as the Director of Sales and Marketing at a prestigious 4-star resort.

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