What is Medical Credentialing?
The Ancient Practice of Credentialing
Medical credentialing dates back to Persia in 1000 BC, as outlined by the Cult of Zoroaster. In ancient Persia, to qualify for licensure, a physician had to treat three heretics — if they lived, that qualified the physician to practice medicine for the rest of their natural life.
While credentialing has changed dramatically in the intervening millennia, the core of the concept is still the same — ensuring doctors who are practicing in a given state or city have received all the necessary training and experience to safely and efficiently practice medicine.
The Modern Practice of Medical Credentialing
Modern credentialing reviews a host of different pieces of information for each medical professional, including:
- Education and training
- Specialty certificates
- Career history
A medical professional must complete this review when they start at a new practice or change states.
Medical credentialing and privileging usually consists of a few different processes: provider credentialing, provider enrollment, and privileging.
Provider Credentialing – the process of verifying the skills, training, licensing, qualifications, etc. mentioned above
Provider Enrollment – the process of enrolling a provider with insurance plans.
Privileging – approving providers to perform specific procedures and granting them a specific set of privileges
Medical credentialing is not only a critical component of developing a practice that delivers the highest level of patient care, it’s essential for insurance reimbursement.
Through the credentialing process, states and insurance providers determine which medical providers meet their requirements.
Things to Know About Credentialing
What do you need to know before signing up for credentialing in any given state or market?
First, it’s important to know that it takes a while. Credentialing can take anywhere from 90 to 150 days, depending on the market. Give yourself plenty of time to complete your credentialing.
Make sure you fill out the application paperwork completely. Missing information, such as work history, current work status, the state of your malpractice insurance or any current hospital privileges you have should all be included. Don’t forget your attestations — the paperwork that ensures your forms are accurate and valid. If you must change any information after the application has been completed, you’ll have to rewrite and resubmit your attestation.
Staying current with relevant organizations, like the Coalition for Affordable Quality Healthcare (CAQH), can help make your credentialing process a little simpler.
Each state has specific credentialing laws and regulations, so make sure you’re aware of any particular rules that could apply to your situation. If you’re changing states, take some time to learn the credentialing laws of your new state, so you don’t miss anything significant.
By keeping up with your paperwork and adhering to the letter of the law, you can ensure you’ll be able to practice safely and legally going forward. In a later section, we provide tips for expediting the medical credentialing process.
Note: With some commercial payers contracting is done separately from credentialing.
Verifying Professional Information
Several organizations handle the information necessary for primary credentialing. Each state runs its own licensing program, and that program will often be broken down further, separating doctors from registered nurses.
The National Student Clearing House contains education history, allowing a doctor or nurse’s education to be verified, while the National Practitioner Data Bank (NPDB) holds information on medical malpractices claims, license suspensions or revocations and other negative events in a professional’s past.
Once a provider is credentialed with an insurance company, they enter into a contract with the insurance company. This contract allows them to bill and be reimbursed as an in-network provider with that insurance company.
While hospitals and larger healthcare organizations often have staff dedicated to managing medical credentialing, many smaller practices must help their medical staff and candidates navigate the credentialing process without the benefit of a devoted medical credentialing department.
Recredentialing, also known as re-enrollment and revalidation occurs periodically and requires a provider to repeat the credentialing process. Providers will receive a letter letting them know that they are up for re-credentialing. If they don’t complete this within the deadline, their credentialing are suspended until the process is completed and approved.
Tips for Streamlining the Medical Credentialing Process
If you don’t have a team devoted to credentialing new medical staff/medical staff candidates and aren’t hiring an outside firm to handle the credentialing process, there are several things you can do to help practitioners navigate the process as efficiently and painlessly as possible.
1) Have medical staff/candidates start the process as early as possible. It’s not uncommon for the credentialing process to take three to four months or longer. When possible, have medical staff/candidates start the credentialing process at least four months before their expected start date at your practice.
2) Give medical staff/candidates a credentialing packet. The credentialing process can be overwhelming. If you are asking medical staff/candidates to take primary responsibility for completing the credentialing process, providing them with key information about your practice will go a long way in making them feel supported and helping them complete credentialing applications more quickly. Some information you should include in the credentialing packet includes:
- Your practice and remit address
- Taxpayer Identification Number (TIN)
- National Provider Identifier-2 (NPI-2)
- Phone and fax number
- A completed W9 for your practice
- Instructions on how to apply for Council on Affordable Quality Healthcare (CAQH) and National Provider Identifier (NPI) numbers
- A list of insurance companies with which you’d like them to apply and links to online applications, where available
3) Keep track of where medical staff/candidates are in the credentialing process and help mitigate delays, when needed. Whether your practice uses an Excel spreadsheet or a credentialing software system, keep tabs on where each medical staff member/candidate is in the credentialing process and help mitigate delays promptly. Remember: Delays in the credentialing process can result in revenue delays or loss for your practice. It is critical that new doctors aren’t rendering any services until they receive an approval confirmation and/or a welcome letter.
4) Make a medical staff member’s start date contingent on submission of all credentialing paperwork. Some credentialing experts suggest linking a provider’s start date to their submission of all credentialing paperwork. For example, you might have a physician start no sooner than 120 days from the date they submitted all necessary credentialing paperwork. Tying start date to paperwork submission date may help avoid the need to schedule around payers with which the new provider is not yet credentialed and allows the new provider to fill their schedule more quickly.
In short, while medical credentialing can be time-consuming, it’s necessary for insurance reimbursement and to ensure your patients are receiving high-quality care from qualified providers.