The Provider Credentialing Process Explained
Credentialing a new provider to validate his or her qualifications, work history, board certifications and references are critical for all healthcare organizations as well as smaller 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 inclusion of a new provider in all of an organization’s insurance plans, ensuring that correct and full payment is received for their services.
Provider Credentialing with payers often takes longer than completing the privileging portion. A recent survey of 500 healthcare industry leaders found that 67 percent of privileging processes take longer than five to six weeks, with many reporting a time frame for provider enrollment taking between 60 to 120 days.
Common Pitfalls Encountered in Performing Credentialing
- Incorrect or outdated data from different systems that are non-interoperable as opposed to using a cloud-based, enterprise-wide platform connecting practices, providers and insurers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, IT, human resources and risk management and payers as well as medical staff, to keep the credentialing process flowing smoothly.
8 Tips for Expediting the Provider Credentialing Process
1. Start the process early
Set a goal of having everything you need ready to go as early as possible. This includes incoming provider documents such as a CV, references with email/ updated phone numbers, etc., now rather than waiting until 2 or 3 months prior to their scheduled start.
However, remember that while some payers refuse to start credentialing a new provider until a maximum of 60- 90 days before they begin work, you do not have to wait until then to start the information-gathering process.
2. Use a cloud-based, enterprise-wide technology platform
Using cloud-based technology allows hospital privileging and provider enrollment staff, as well as administrators and medical providers to access provider data at any time or location. Client server-based systems, on the other hand, slow down the process by making it harder to access and share data.
3. Incentivize new providers
Taking too much time to credential new providers usually impacts the practice’s finances more than the provider’s, who normally can expect a guaranteed salary. You may wish to link the start date with the submission of credentialing paperwork. For example, the start date will be no sooner than 120 days following complete, accurate document and information submission.
4. Five references are better than three
Most payers require at least three professional references and normally won’t start the approval process until these are received. Just one lagging reference could hold up the whole process, so asking for five instead of just three should help keep everything on track, in case one is delayed.
5. Timing is important – be proactive
Since many payers are overwhelmed with new-provider applications, especially in the summer following graduations, you should expect some delays if you wait until then. Keeping tabs on the process with the credentialing folks by notifying when an application is sent as well as checking in weekly, can often help expedite matters and keep you and your staff in the loop as to the approval status.
6. Outsource your credentialing
Good credentialing services understand and routinely navigate the credentialing process daily, so using a service can cut the credentialing waiting time by days or weeks. Remember that certain advanced practice professionals (APPs) such as NPs and PAs, don’t often follow the summer graduation schedules, with frequently having fewer than 60 days between hiring and start dates, making outsourcing credentialing a great timesaver.
7. Detail issues can spell delays
Many payers report that as many as three in four applications are delayed due to omissions and mistakes. It’s important, therefore, to get everything right the first time. This can be where a good outside credentialing service really shines: because of their familiarity with the process, they can immediately spot problems and work to get the problems quickly resolved and things moving again.
Most common causes of delays:
- Incomplete work history, including failure to explain time gaps of 30 or more days
- Incomplete malpractice history, including proof of coverage, with your practice as of the start date
- Professional references missing or incomplete
- Unconfirmed hospital privileges and /or covering colleagues (sending a letter with the credentialing application confirming coverage is a good proactive measure to make sure this base is covered)
- Outdated information in the credentialing database of the Coalition for Affordable Quality Healthcare
8. Be familiar with your state’s credentialing regulations
Some states permit reciprocity, where a provider credentialed in one state can be credentialed (with the same payer) in another. Additionally, some states allow a provider to bill for services provided during the credentialing process. Check with your state’s chapter of the Medical Group Management Association or medical society to be sure that you’re using any applicable regulations to your advantage.
Non-Credentialed Providers Cost the Practice Money
Remember that an uncredentialed provider, who may be receiving a salary while awaiting completion of the process, is really expensive overhead. By starting the process early, checking for accuracy and completeness and regularly following-up, practices can stay on track and prevent expensive and frustrating delays.
Consider Outsourcing to a Local Medical Billing Service Company
Since 2002 M-Scribe has been helping practices of all sizes and specialties with their medical billing, pre-auditing and risk assessment, as well as assisting with credentialing to make the approval process more efficient and faster with fewer delays due to missing or incorrect information. Our credentialing experts are experienced with CAQH registration and can advise you every step of the way. Contact us at 770-666-0470 or email to learn more about how teaming up with an experienced medical billing and practice management service can keep you fully compliant while increasing your revenues and bottom line.