Credentialing takes time, but unless your physicians and providers are fully credentialed it can delay your reimbursement – or even cause it to be denied entirely. The credentialing process includes verifying the provider’s expertise and abilities and is essential if you accept insurance; you can’t bill an insurance company without it.
Credentialing takes time; when a new provider or associate joins your practice it could take weeks or even months to process the paperwork. Beginning the process when you make an offer can help expedite things; early, accurate paperwork can help speed the process along.
Create an Efficient Credentialing Process
Put someone in charge: Decide which team member will handle credentialing and the details that go with it. They’ll need to cover not only new providers, but re-credentialing for existing providers as well. Your payers, hospitals and other third parties may have specific requirements and deadlines for credentialing; having one employee in charge of this operation ensures the information remains in one place and the all tasks are being completed.
Fully complete the application: Even a single unfilled spot on a form could delay your credentialing process. Fill out all forms completely and provide the requested documentation at the time of the application. Anything you leave out, even a blank space or unticked box could cause delays.
Schedule time for completion with the provider in question; a new application will take several hours to complete and you may have to meet several times. They’ll have to provide both basic information, including details about their education, professional experience and even professional conduct. Your re-credentialing paperwork won’t take as long to complete, since some of this information will already be available to you from previous credentialing, but a new hire will need time to fully and accurately complete the application.
Primary Source Verification (PSV): You’ll need to verify the information the provider gave you; their self-reported information must be compared with a primary or originating source. Each piece must be verified and documented; for the provider’s medical license, the PSV or originating source would be your state medical board or department of health. You’ll need to verify many items besides the medical license, including:
- Education: The PSV would be the candidate medical school, the AMA or the National Student Clearinghouse
- Board Certification: The American Board of Medical Specialties (ABMS) is the PSV to check for certification.
- Sanctions: Check both your state Medicaid sanction list and the Offices of the Inspector General and System for Award Management (SAM) for sanctions.
- Malpractice: The PSV for malpractice is the National Practitioner Databank
- NPI: The PSV for NPI is the National Plan and Provider Enumeration System (NPPES)
- DEA Registration: Check the National Technical Information Service
You also may need to include an affiliation history, military service history, a background check, one or more peer reference letters and a detailed list of hospital privileges from the last 5-10 years.
Approval: Once the information is complete and verified, you can submit it to the correct authority. By taking the time to work with your providers and fully complete the paperwork, then verifying the accuracy of each piece, you can speed up the process by anticipating what documentation may be needed and including it in the package.
Each hospital or payer has slightly different forms and processes, so maintaining accurate records of the providers in your practice allows you to efficiently complete new credentialing documentation for privileges. Prompt attention to credentialing requests can ensure your revenue stream stays steady and that your physicians can actually bill for their services and see patients at local hospitals and facilities.