Credentialing is essential for establishing a successful medical practice. In a nutshell, credentialing is the process of determining whether or not a healthcare provider is qualified to perform medical services. Checking that providers have the necessary education, training, residency, licenses, and specialty certificates to do their jobs is part of this process.
Credentialing is essential for establishing a successful practice because it protects patients, prevents revenue loss, and boosts patient confidence by ensuring that all healthcare workers are held to the same high standard. Here are the six things you need to know about credentialing to help your practice thrive and get paid for the services you provide, whether you have an established practice or are looking to start one.
How Medical Credential Works
Medical credentialing is a market-driven process that aims to keep medical standards high for the benefit of patients. To confirm the provider’s credentials, the credentialing authority (known as a Credentials Verification Organization, or CVO) will contact the university where the provider received their medical degree, training, and residency.
They will also check licenses and specialty certificates with certification boards and licensing agencies. Work history can be confirmed by hospitals and other employers. Credentialing is required for all new hires, but it is also required at regular intervals after hire to ensure compliance with regulatory and accrediting organizations such as The Joint Commission (TJC), CMS, and the National Committee for Quality Assurance (NCQA).
1. Credentialing Improves Patient Confidence
Medical credentialing ensures that the medical industry is of high quality. Hospitals and clinics can be confident that the staff, they hire will provide quality care in accordance with the standards expected of them because of credentialing.
Medical credentialing benefits practitioners because it allows them to expand the number of patients they can see once they are enrolled with multiple insurance companies. Finally, and perhaps most importantly, patients gain peace of mind knowing that the medical industry is committed to upholding high standards and ensuring that they receive the best possible care from their healthcare providers.
The most important goal of healthcare credentialing is to ensure that the people who are providing their medical care are qualified and competent to do so. Patients can rest assured that their healthcare provider’s qualifications and experience have been thoroughly evaluated through credentialing. Patients can have confidence and trust in their healthcare provider as a result of this.
A thorough credentialing process can also prevent the admission of untrustworthy or dishonest providers. Most healthcare workers recognize that caring for patients is a privilege and that this privilege comes with being properly credentialed.
2. Accurate Credentialing Prevents Revenue Loss
The beginning of your practice’s revenue cycle is credentialing and enrollment. To treat patients, you must be credentialed, and you must be enrolled with insurance companies to be paid. Delays or lapses in these processes can cause reimbursement to be delayed or even denied, affecting your cash flow significantly.
Because all reimbursement is dependent on credentialing, it is a critical part of the revenue cycle management healthcare process. Before seeing patients and billing for their services, new providers must wait for their credentialing to be completed.
If currently practicing physicians let their credentials lapse, they will not be eligible for insurance reimbursement until their credentials are verified and approved. Through accurate and timely credentialing, you and your staff can avoid claim denials and other harm to your revenue cycle. You can achieve revenue integrity and receive optimal reimbursement for the services you provide by avoiding mistakes and completing the credentialing and re-credentialing processes as quickly as possible.
3. Accurate and complete documentation is required
A lack of attention to detail is the most common mistake made during the credentialing process. Credentialing necessitates a large amount of paperwork, which must be filled out completely and accurately. Missing information or entering data incorrectly can cause the credentialing process to be delayed for weeks, leading to application rejection. Accuracy is crucial, and getting it right the first time means getting approval faster.
Most healthcare organizations develop credentialing programs that meet the National Committee for Quality Assurance’s minimum credentialing requirements (NCQA). In order to comply with these requirements, you should gather and organize your paperwork in such a way that you have the necessary records and proof of due diligence in the event of a denial or audit.
4. Get Involved Early and Stay Involved
Don’t procrastinate getting your credentialing started! You can help expedite the process by ensuring that your paperwork is correctly and thoroughly filled out, and by providing all required supporting documentation. You can also contact your verification sources and request that they send all verification responses as quickly as possible.
No one is more concerned about your application than you are, or should be. The only way to find out how your application is progressing is to follow up on a regular basis.
5. Different Credentialing Requirements
It’s critical that a provider’s credentials are always up to date and accurate. The requirements for credentialing vary from state to state, as well as between medical facilities and insurance companies. State credentialing laws vary and can be influenced by new legislation. It’s critical to keep an eye out for updates and changes in regulations and to update your credentialing procedures as needed. This will help you avoid unpleasant surprises, which could cause delays in your credentialing procedures.
6. RCM Coordination and Credentialing
The foundation of a medical practice’s revenue cycle is credentialing. Poor credentialing will cost your practice a lot of money. Payment delays, denials, lost revenue, out-of-network services, and unhappy patients are all consequences of a credentialing issue. Trying to understand and manage your practice’s or healthcare organization’s credentialing requirements can be time-consuming and draining.
Credentialing services include the following:
- Preparation of the application, including Verification of Primary Sources
- Enterprise Credentialing Information Tracking Tool for Early Detection of Errors and Missing Information
- Provider Facility for Dedicated Account Representatives Re-credentialing
- Medical Licenses and Renewals for Providers
