Credentialing a new provider to validate his or her qualifications, work history, board certifications, and references is critical for all healthcare organizations as well as smaller and medium-sized practices.
Normally, there are two separate processes to credentialing:
- Privileging approves a provider for performing a specific set of privileges or performing certain specific procedures.
- Provider enrollment is the inclusion of a new provider in all of an organization’s insurance plans, ensuring that correct and full payment is received for their services.
What is meant by Provider Insurance Credentialing?
Insurance Credentialing (also known as “provider enrollment”) is the process when a healthcare provider applies to health insurance networks to be included in their provider panels once the internal requirements for education, experience, and related criteria are met. Once approved by the credentialing board, they may begin the contract phase to fully participate in providing privileges and reimbursable services or care for a healthcare organization.
Why is Credentialing important?
When correctly structured, the credentialing process can prevent the admission of unqualified healthcare workers to the healthcare system as well as within a provider network. Ideally, all healthcare workers should be periodically audited following initial credentialing, for both performance and qualification updates.
Credentialing with insurance networks is important for the provider, and affiliated facilities, as participation is necessary for the provider’s income. Starting the process early, checking for accuracy and completeness, and performing regular follow-up ensures staying on track to completion and increasing revenue.
Why choose a Provider Insurance Credentialing Service?
Time is money, whether for a healthcare provider or the facility charged with undertaking credentialing. There is a lengthy time frame needed to complete and review the application, including following-up on the credentialing status, ensuring that the correct documentation is received, as well as working within the credentialing board’s schedule.
What is needed for Provider Insurance Credentialing?
The provider will need to submit the following information:
- Proof of Education
- Proof of Training, including board-certification(s)
- History of prior employment, if applicable
- Other information necessary to assess his or her qualifications for inclusion as a contracted provider
Common pitfalls encountered in performing credentialing:
- Incorrect or outdated information from different systems that are non-interoperable as opposed to using a cloud-based, enterprise-wide platform connecting practices, providers and insurers with a single unified platform.
- Processing delays from incorrect or missing data that cost revenue, such as missing references or incomplete work history, that are required by payers before they will reimburse for services.
- Failure to communicate between all departments, including finance, human resources. IT, risk management and contractual payers, as well as medical staff, to keep the credentialing process flowing smoothly.
Credentialing is really a team effort, requiring all resources involved, to work with the medical staff and provider enrollment personnel to ensure that the process is completed with as little loss of revenue as possible.
Why does Credentialing take so long?
For the provider’s part, it takes several hours to fill out the numerous forms required; however, for the facility’s office staffers, the process can take as much as 20 hours (or more) per credentialed provider to complete the following tasks:
- Initiating background checks
- Collecting and verifying credentials, reputation and case history
- Collect/review claims privileging and board certification history
- Check for sanctions by the Inspector General’s office
- Start verification of primary sources, including applicable medical boards, the AMA, and education
- Turning the files over to the credentialing and executive committees as well as stakeholders of the facility
- Provide an appointment letter establishing privileges and other conditions to be met
Of course, the time frame can vary wildly depending on many factors, including missing or inaccurate information from the provider’s initial application, slow responses from an education institution, former employer, or other references, as well as lack of openings in the credentialing board’s schedule – all of which can add weeks or even months to the process, costing both the provider and facility thousands of dollars in lost income and wasteful administrative spending.
Bikham’s Enrollment and Physician Credentialing Services
Bikham offers complete credentialing services for single practitioners, group practices, laboratories, nursing facilities, and others, enhancing approval by reducing mistakes that can hamper completion, costing everyone time and income. Bikham performs network research, application filing, follow-up, closed-panel appeals, out-of-network enrollments, and annual credentialing maintenance.
To streamline the workflow, applicants will receive a checklist of required documents and other information which is then filed by the Bikham Credentialing Team to the appropriate payers pre-selected by our client organizations. Equally important is the follow-up performed, ensuring the receipt of the information as well as processing status.
When it’s time to consider outsourcing, work with an established practice management company.
Since 2006, Bikham has been helping practices of all sizes and specialties with their credentialing needs to help make the process more efficient, smooth, and less time-consuming. Contact Bikham either by email or phone at 1-800-940-4943 to learn how they can take the guesswork out of the credentialing process, and ensure a smoother workflow for faster results.
