Did you know that out of every five healthcare service claims filed in the USA, one belongs to an
out-of-network provider? Being impaneled with leading insurance companies helps the healthcare
providers to improve their revenue cycle. More patients opt for healthcare services that their
insurance will cover so that they have lesser out-of-pocket expenditures. Right provider
credentialing is the key for healthcare providers to get in the panel of reputed insurance
companies.
You might have heard all this information elsewhere too. But what no one tells you is how
complicated the process of provider credentialing can be! It is challenging for beginners who are
just starting on their own. In this article, we have tried to compile the most frequently asked
questions, the tricky issues, and reasons why you should start preparing for provider credentialing
if you have not already! Here’s a guide for all beginners.
1.What do you mean by provider credentialing?
Provider credentialing is the process through which the educational qualifications and the clinical
competence of the healthcare providers are analyzed and verified. From their medical school
certificate to their latest professional training, each document of the provider is collected. Apart
from these, the credentialing teams also verify the DEA certificates and other federal requirements.
2.What are the documents needed in provider credentialing?
Collection and verification of several documents of the healthcare provider complete the provider
credentialing process. While some primary documents are standard for all, requirements of particular
states, local governments, and insurance panels are specific. Here is a list that you will find
helpful:
Demographic details of the provider
Detailed contact information
Immunization Records
Medical School Diploma
Certifications of professional training and residency
Fellowship certificates (if any)
Federal Tax ID
Board certification document (if any)
Proof of Continuing Medical Education (CME)
Professional Liability Insurance Coverage
Any history of malpractice with proper documentation
Medicare and Medicaid details
If you are a foreign medical school graduate, you will additionally need the following papers:
ECFMG certificate or Fifth Pathway Program details
All non-US citizens also need to show a copy of their visa status or permanent resident card, or
green card, as applicable.
3.Who performs the credentialing procedure?
Provider credentialing is essential both for the healthcare organizations and the insurance panels.
Therefore they perform the procedure separately with certain modifications. Here are some pointers
for beginners to note:
Government Payers:
Government payers like The Centers for Medicare and Medicaid Services have enrollment forms on their
web portals and document requirements.
They perform the credentialing process through their teams to accommodate the providers in their
varied plans like Medicare Part A or Part B.
Private Insurance:
Providers can also enroll themselves in the different leading insurance panels like UnitedHealth or
Cigna.
However, they have limited seats on their panel. The providers should keep an eye out for the
openings of their choice.
The requirements for the separate plans under the same panel might be different. So you should check
them out as well.
Healthcare Organizations:
Healthcare organizations have primarily two goals when performing provider credentialing.
Firstly, they will verify the provider’s documents to understand if they have the required clinical
competence and professional efficiency needed for the role.
The same data collected will be used by them to enroll the providers in different insurance panels.
The correct documentation will pave the way for timely reimbursements and keep the organization’s
revenue cycle strong.
4.What are the different steps of provider credentialing?
Now that you know the stakeholders involved and the documents needed for the process, here is a
stepwise guide for you.
Prepare a checklist of documents needed by a particular stakeholder.
Collect the papers and fill in the credentialing forms.
Check for any mistakes that might delay the approval process.
Submit the forms with the required documents to the authorities.
In the case of insurance carriers, make sure you follow up with them frequently to know the status
of your application.
5.How can you choose the right payers for you?
Most healthcare providers want to get in top panels of leading insurance payers. But most of the
time, it does not happen as there is a shortage of seats. Here are few tips to get credentialed by
the payer networks:
If you are looking for Government plans like Medicare and Medicaid, you should submit your
application early and without any errors.
For private insurance companies, keep a daily tab on the openings of your choice.
The same panel might have different plans. So make sure you choose one that fits your needs.
Keep an eye out for the local insurance payers as well. There might be a more significant number of
patients in a local area who have subscribed to these panels. You do not want to miss them!
6.How can you avoid any delays in credentialing completion?
Provider credentialing is undoubtedly a lengthy and cumbersome task where you need to be cautious
about every move you make and every form you fill out. One small mistake can delay this process for
too long and harm your cash flow.
The credentialing process takes around 90 to 120 days to finish.
The key is to start early with your applications so that you have the required time to review your
errors.
Following up with the insurance payers is a must. So make sure you do that frequently regularly.
7.Is outsourcing provider credentialing a good option?
Yes! Outsourcing is a very effective as well as an economical option for provider credentialing.
Outsourcing will give you the following benefits:
The leading companies will take the burden of the
enormous paperwork off your shoulders and compile them.
They will keep an eye out for the insurance panels you wish to be a part of. They can also suggest
some suitable options.
Their teams will coordinate with the insurance panels regularly to follow up on your application.
Some companies use homegrown software solutions to simplify the provider credentialing process. This
helps in error-proofing the applications.
The returns on investment are high. They will ensure that you are in-network. But you need not
invest any time and energy in the entire process.
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