Top 7 Questions on Provider Credentialing Decoded

Provider credentialing is one of the medical industry’s lengthiest and cumbersome administrative processes. But it is imperative to make sure that each process is completed with care for the revenue cycle and reimbursements to run smoothly. Provider credentialing has long drawn effects on the workflow management of medical organizations. According to a recent poll by the Medical Group Management Association (MGMA), more than 50% of healthcare organizations reported that they had witnessed an increased number of denials due to erroneous provider credentialing in 2021.

According to the Regulatory Overload Report of the American Hospital Association, healthcare organizations spend over $39 billion in a year to make sure that they are compliant with the updated regulations of the federal and state authorities. One clerical error can disrupt the entire process, leading healthcare organizations to suffer from heavy financial losses. Provider credentialing also has its rules changing every year. To avoid claim denials and other legal hassles, a provider/credentialing staff must stay clear on any queries that they might have.

This article will answer some of the top questions related to provider credentialing:

1. What are the different types of provider credentialing processes?

Provider credentialing is a broad term used to denote the verification process of a provider’s competence. However, it is used in different formats in separate medical organization setups.

  • Organizational provider credentialing is done to verify if the healthcare practitioner they are recruiting is true to the qualities required for the role. They collect and verify the different skills depending on the recruiting position.
  • On the other hand, insurance provider credentialing is done by the insurance payer panels to onboard the providers to their networks. While Government payers like CMS have streamlined credentialing packets, private networks vary in their requirements.

2. Which authorities regulate the provider credentialing process in the USA?

Credentialing guidelines are diverse in the USA. However, all other institutions abide by specific rules and regulations laid down by the federal and state bodies. It is essential to know these authorities since they will help you stay updated on the latest methods.

  • The Centers for Medicare and Medicaid Services (CMS)
  • The Joint Commission (TJC)
  • The Accreditation Association for Ambulatory Healthcare (AAAHC)
  • The National Committee for Quality Assurance (NCQA)
  • Det Norske Veritas (DNV)
  • Utilization Review Accreditation Commission (URAC)

3. What are the basic details requested in a credentialing packet?

Insurance panels differ by their provider credentialing detail requirements and formats. However, some of the essential details are common for all. Keep these details updated, to begin with:

  • Demographic details
  • Full mailing address
  • Detailed curriculum vitae
  • Citizenship data
  • Medical school graduation and training details
  • Residency details
  • Specialties and sub-specialty details, if any
  • Valid state licenses
  • Professional liability insurance details
  • Board certification, if any
  • Continuing medical education papers
  • History of malpractice claims
  • NPI number
  • Practice TIN
  • History of any past disciplinary actions with explanation

4. How long does the provider credentialing process take to get completed?

  • Ideally, provider credentialing should get completed within 60 to 120 days if the provider furnishes all information and detailed documentation correctly the first time around.
  • However, the verification process can take a while, and any hurdles or clerical errors in the way could push it further by even as much as a year.
  • The process gets delayed due to petition or appealing procedures.

5. How important is CAQH in the credentialing procedure?

  • The Council for Affordable Quality Healthcare plays a critical role in the provider credentialing process.
  • CAQH ProView hosts professional information from more than 1 million healthcare providers.
  • Most insurance panels try to collect and verify the providers’ credentials through this platform. It also becomes easier for the providers to apply to different panels through the same profile.
  • Though not mandatory, insurance panels prefer that providers have their verified profiles on the CAQH platform.
  • If you do not have a CAQH profile, it is advisable to start applying early since the verification process can take quite some time.
  • Experts also believe that providers should apply and complete the application process online and not through paper submission to expedite the procedure.

6. What steps can a provider take to speed up the process?

  • The provider should be careful about the information they submit to the final review panel. Any slight error could delay the process further.
  • You should also check if there are any unanswered questions on the form. Forms often come back due to being incomplete.
  • In case of any dispute of the past, make sure you provide sufficient explanation along with the documentation. This helps the review team to make a clear decision without pushing papers back and forth.
  • In case of board certifications or any other renewable certification, ensure that the documents are up to date and not expired. Review and revise the documents beforehand to avoid any delay.
  • Getting your profile on an automation software tool is advisable if the significant volume of documentation is too overwhelming for you.
  • Software tools are excellent partners to eliminate unnecessary manual errors that are often difficult to make out in traditional ways. The fewer the mistakes, the faster the provider credentialing procedure.

7. How often do you need to repeat the process of credentialing?

  • The period of re-credentialing depends on the insurance panel. However, the provider needs to refurbish and verify the information at least once every three years.
  • Some insurance panels also need healthcare professionals to update their information once every two years.
  • The provider must track the different credentialing timelines for separate insurance panels since a gap in credentials would lead to failed reimbursements.

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