Physician credentialing is the process of obtaining, verifying, and organizing information that documents training, qualifications, and work history of medical practitioners. Payers use this information to determine if physicians have the necessary professional experience to provide healthcare services to their beneficiaries. It is complex and time-consuming, and errors such as incorrect documents or missing signatures can slow an already cumbersome and lengthy process down even further. The unfortunate result is massive delays in on-boarding of critically needed medical professionals which ultimately leads to compromised patient care and loss of provider revenue.
Why Does a Physician Need Credentialing Services?
Medical credentialing services are absolutely necessary for payment by commercial insurance carriers, including but not limited to: Aetna, Tricare, and Cigna. Government insurance, such as Medicare and Medicaid, also require credentialing. Effective credentialing is foundational to high-quality patient care.
What Information is Required for Credentialing?
Specific credentialing requirements vary on several levels. Commercial insurance carriers differ in their precise requirements and credentialing processes. Government health programs, such as Medicare and Medicaid, however, have more uniform requirements across the U.S. Individual states may have their own rules and regulations for credentialing as well.
Several credentialing obligations are consistent among states, commercial insurance carriers, and government health programs. These include and are not limited to:
- National Provider Identifier (NPI)
- Education and residencies
- Specialties and specialized training
- Board certifications
- Drug Enforcement Agency (DEA) registration
- Documentation of liability insurance
- Malpractice claims (if any)
- Work history
- History of loss or limitation of hospital privileges
Some larger carriers, such as Aetna, also have interim monitoring programs that review issues such as sanctions, member complaints, or loss of license.
Should my Billing Company do my Payer Credentialing?
It is possible for a billing company to also provide physician credentialing services as long as the necessary expertise can be confirmed. Bikham Healthcare has done the comprehensive network research and data analysis that provide clients with a highly effective revenue-building mix. In all cases, credentialing account managers work closely with billing managers to maximize opportunities for obtaining enrollments that also lead to advantages in fee rate negotiations. These collective efforts create the best possible outcome in end-to-end revenue cycle management and patient satisfaction.
How Long Does It Take to Credential a Provider with Insurance Companies?
The length of the entire credentialing process depends on the expertise of the credentialing professionals and the ability of physicians and their organizations to submit the necessary information. From document attainment to final approval, estimates have ranged from 60 to 220 days, depending on the need to correct deficiencies. In some cases, the process may take as long as a year. According to the Center of Medicare and Medicaid Services (CMS), any number of preventable problems can cause costly delays:
- Missing documents
- Fields left blank
- Incorrect signatures
- Missing application fees
CMS estimates that between 30% and 35% of all applications are delayed due to the above issues.
When Does Outsourcing Your Credentialing Make Sense?
During the past 20 years, the medical credentialing process has become progressively more onerous due to expansion in scopes of practice, guidelines instituted by accrediting bodies, and requirements of third-party payers. Furthermore, national and global crises, such as the COVID-19 pandemic, have further intensified the need for expedited on-boarding of all medical personnel, particularly physicians.
The complexities of the credentialing process, market forces, critical patient needs, along with the high price of credentialing delays and denials, accentuate the value of competent and comprehensive outsourcing. Bikham offers years of experience, extensive resources and unmatched professional services that meet and exceed the distinct needs of clients. One of Bikham’s many successes was achieved in 2018, when, in just 14 weeks, the enrollment team assisted a large urology group (22 locations, 110 providers) in developing customized physician credentialing and billing solutions that had been backlogged for at least 6 months. Positive outcomes were seen within the first 30 days – enrolling 22 providers in 66 insurance plans. Ultimately, these dedicated professionals assisted in submitting over $3.5 million in backlogged claims.
How Can I Speed Up My Credentialing?
Applying early is a critical factor in speeding up the credentialing process. Often, new physicians wait until they start their jobs to compile the necessary information. Delays are compounded as they wait for references and other required documents – taking several weeks or even months.
Substantial delays often occur when busy practice managers are besieged by day-to-day obligations of appointments, personnel issues, and billing. They simply don’t have time to stay informed on changing credentialing policies, regulations, and guidelines.
How Much Does Physician Credentialing Cost?
Bikham charges a fixed amount per application:
- 1 – 4 applications: $250 each
- 5 – 9 applications: $220 each
- 10 – 19 applications: $200 each
- 20+ applications: Custom Pricing
Payer enrollment fees range between $2000 and $3600. As expected, these figures become inflated if there are delays in submission, missing documentation, or even missing signatures. This is why Bikham does everything possible to make all aspects of the applications meet the required standards the first time.
Who Can I Contact If I Have More Questions?
Bikham Healthcare is proud to have a proven track record of expedient physician credentialing services at a reasonable cost. The enrollment team has consistently been instrumental in assisting healthcare practices of all types in meeting and exceeding credentialing and revenue goals.
Contact Bikham Healthcare or call (718) 550-1384 to learn about physician credentialing and many other healthcare solutions.