Mastering Provider Credentialing: A Roadmap in 7 Essential Steps

When your facility brings in new doctors, nurses, or healthcare providers, it’s important to take them through the medical credentialing process. This helps check their qualifications and skills and gets them approved by the insurance companies you usually deal with. Even if a healthcare provider was approved by insurance before, they must reapply when starting with a new employer.

Why Credentialing Matters in Healthcare

Let’s talk about why healthcare credentialing is so important before diving into the steps. Healthcare credentialing, also known as insurance or medical credentialing, ensures that providers have the right qualifications. This is crucial for facilities to process insurance claims and offer accessible care, even for uninsured or self-paying clients.

Different healthcare providers, like physicians, hospitals, dentists, physical therapists, and counselors, all have unique credentialing processes. It’s not just about doctors; it applies to various healthcare entities. However, medical billing and credentialing services play an active role in the credentialing process of healthcare providers. When they are doing it by themselves, it does take a very long time in case there are some errors in the credentialing process. 

If you want to accept Medicare and Medicaid, your credentialing process must meet guidelines set by federal agencies like the Centers for Medicare & Medicaid Services (CMS) and The Joint Commission on Accreditation of Healthcare Organizations. Additionally, each state has its own credentialing rules, which, when followed closely, can lower your practice’s liability in case of malpractice claims.

Though credentialing can be time-consuming and tedious, it’s essential. To ensure your healthcare providers get the right credentials promptly, follow these steps.

Step 1: Collect Necessary Documents

When starting the provider credentialing process, note that each insurance company has different forms and requirements. To work with them, you must send complete applications. Missing even one piece of info can delay approval by weeks or months.

To make sure your applications are complete, follow these steps:

• List all insurance companies you want to work with.
• List all required documents, including:
• Name
• Social security number
• Demographic info (ethnicity, gender, citizenship, languages spoken)
• Education and residency details
• Proof of licensure
• Career history
• Specialties and patient focus
• Claim history
• Proof of insurance
• Info about your healthcare facility

Much of this data might be in your healthcare provider’s resume, but you need to verify its accuracy.

Step 2: Prioritize Insurance Companies

Since you’ll be submitting multiple applications, it’s helpful to prioritize which ones you submit first. Consider the following:

• If a large part of your billing goes through one insurer, start with their application.
• Be aware of individual insurers’ rules. Some, like Aetna, offer a faster process for providers already insured in another state.
• Certain providers may have a shorter application for those already credentialed in-state.
• Make a list of priorities and gather your documents accordingly.

• Make Sure Your Information is Right

When you’re getting together all the needed papers and filling out applications, remember that having accurate info is crucial. Before you send in any application for provider credentialing, do these things:

• Do a background check.
• Check if the education history, licenses, board certification, references, clinical privileges, and reputation are correct. You can do this through organizations like the American Medical Association (AMA), the Educational Commission for Foreign Medical Graduates Certification (ECFMG), and the American Board of Medical Specialties.
• Look into the history of credentialing, privileges, and insurance claims.
• Write down any sanctions that are listed with the Office of Inspector General (OIG).

If there are mistakes in what you send, it can cause problems. For example:

• If the months and dates of employment can’t be checked easily and correctly by past employers, fixing the application with the right info can slow down the approval process.
• Wrong phone numbers for references or past employers can make things slow or even cause rejections.
• Leaving out past malpractice claims could mean you don’t qualify.

Once you’ve got and checked these papers for your medical providers, you can show them to the leaders at the facility. They’ll decide what specific privileges to give to the new provider. This info is really important for the credentialing process.

Manual Checking vs. Other Ways

Should your facility check credentials the old way, by calling and emailing schools and organizations? Some places do this, but it takes a lot of time. And if you skip steps, it can cause more delays. Other ways to do it include:

• Using credentialing software like Modio and Ready Doc. These programs check resume and application info against AMA profiles, medical schools, the OIG, and more.
• Outsourcing – If your HR department is too busy, getting help from a credentialing service can save time and money.

Once you’re sure your info is right, you can move on to the next step.

Applying for CAQH

Many big healthcare insurance companies need partner facilities to get provider credentials through the Council for Affordable Quality Healthcare (along with completing their own applications). Here’s how it works:

Apply to an individual insurer. They will give you a CAQH number and an invite to apply.

You can fill out the CAQH form on paper or online. It’s better to do it on a computer because if you use paper, CAQH has to manually enter the data.

Inaccurate or incomplete info can delay CAQH approval, just like with individual insurers.

After the first application, be ready for re-attestation. This means confirming a healthcare provider’s info is correct four times a year to keep insurance eligibility.

Following Up

Waiting for an insurance response for months isn’t the best approach. Healthcare professionals who handle credentialing recommend staying in touch regularly for faster approval. Here are some tips:

Build connections with important people at the insurance company. Having a good relationship with leaders, executive assistants, and staff ensures your applications move forward quickly.

Use phone check-ins instead of emails for better chances of getting a response.

If you’re told more info is needed, gather and confirm all documents promptly.

Renewal Process

Your healthcare providers get their insurance panel approval, but it’s not forever. Unfortunately, it’s an ongoing process. Finding a mistake in an employee’s info? Tell the insurers ASAP. If they catch it before your formal correction, they might revoke it.

Most providers need a renewal every three years. Credentialing software helps manage this and reminds you when it’s time. But insurers will also remind you after three years. Respond quickly so your provider can keep caring for patients without interruption.