Author image - Revenue Cycle Management with Adonis

Dan Murdoch

August 30, 2023
Share This Content:

Credentialing 101: What Physicians Need To Know

Credentialing 101: What Physicians Need To Know

In the realm of healthcare, credentialing stands as a cornerstone for both patient care and the seamless function of medical establishments. At its core, credentialing is about verifying a physician's qualifications, ensuring they're permitted to provide specific services, and also facilitating their collaboration with insurance carriers. Here's an in-depth look into credentialing, why it matters, and essential pointers for physicians.

Why is Credentialing Indispensable?

Credentialing is pivotal for physicians intending to collaborate with insurance carriers, both commercial and governmental. Organizations like Aetna, Tricare, Cigna, Medicare, and Medicaid necessitate this process. This isn't merely bureaucratic; it's also a foundational step towards safeguarding the quality of patient care. Through credentialing, patients can be confident in the qualifications and expertise of their healthcare providers.

Key Information for Credentialing

While requirements can fluctuate depending on the carrier or state, certain components remain consistent across the board:

  1. National Provider Identifier (NPI): A unique 10-digit identification number for healthcare providers.
  2. Educational Background: Covering medical education and any residencies undertaken.
  3. Specializations: Focusing on specialties, board certifications, and any specialized training.
  4. Drug Enforcement Agency (DEA) Registration: An essential for those prescribing controlled substances.
  5. Liability Insurance Documents: Proof of relevant insurance cover.
  6. Malpractice History: Any past or present malpractice claims.
  7. Professional History: Detailed work experience and history.
  8. Hospital Privileges: Record of any loss or restriction of privileges at hospitals.

Moreover, some carriers, like Aetna, delve deeper, monitoring for sanctions, member complaints, or licensure issues.

The Role of Billing Companies in Credentialing

Traditionally, when we think of billing companies, our minds gravitate towards their primary functions: invoicing and collections. However, the healthcare landscape is evolving, and with it, the roles and responsibilities of these entities. A growing trend in the industry sees billing companies extending their services into the world of credentialing.

What's driving this change? At its heart, both billing and credentialing revolve around a nuanced understanding of the healthcare revenue cycle. Billing companies, having mastered the intricacies of this cycle, find themselves uniquely positioned to facilitate the credentialing process. Their foundational knowledge of patient invoicing, insurance claims, and collections can be harnessed to provide insights into the credentialing workflow, ensuring that healthcare providers are recognized and appropriately compensated for their services.

However, this blending of roles comes with its set of challenges. As billing companies venture into the realm of credentialing, they must acquire a specialized skill set. Credentialing, unlike standard billing processes, demands rigorous verification procedures, adherence to specific regulations, and continuous monitoring. Hence, while a billing company might tout its credentialing services, it's crucial for physicians and healthcare entities to dig deeper. Ensuring that the chosen billing company possesses the necessary expertise, experience, and resources in credentialing is paramount to prevent potential pitfalls down the line.

Duration of the Credentialing Process

For many, the term 'credentialing' may conjure up notions of a quick verification check, but the reality is far more complex. The credentialing journey is intricate, multifaceted, and often prolonged. While the timeline varies based on the involved professionals' efficiency and the readiness of required documents, the procedure typically stretches from 60 to an astounding 220 days.

But why such a wide range? A significant portion of the delay can be attributed to avoidable errors that plague the process. Simple oversights, such as missing documents, incomplete sections of applications, or even forgetting application fees, can derail the timeline substantially. It's disconcerting to note that a significant percentage, almost a third of all credentialing applications, get ensnared in these preventable issues. This not only elongates the wait time for healthcare professionals but can also lead to financial setbacks and operational inefficiencies.

When Outsourcing Credentialing is a Prudent Move

Over the last two decades, credentialing's intricacies have amplified, propelled by evolving scopes of practice, tighter regulations, and payer-specific requirements. Crisis situations, like the COVID-19 pandemic, only intensified the demand for swift onboarding of medical personnel. Given the convoluted nature of the process and the high stakes involving delays, outsourcing to experienced entities makes increasing sense. Expert firms offer a blend of experience, resources, and tailored services, ensuring timely and effective credentialing.

Accelerating the Credentialing Journey

To hasten credentialing, proactivity is key. New physicians often err by initiating the process only upon starting their job, leading to prolonged waits for references and documents. Additionally, with practice managers swamped by daily operational tasks, staying updated on ever-changing credentialing norms becomes challenging. Starting early and staying informed can significantly truncate the waiting period.

Cost Implications

Costs for physician credentialing vary, often based on the number of applications. While there are fixed pricing brackets for varying numbers of applications, fees for payor enrollment oscillate between $2000 to $3600. Delays or errors can further inflate these numbers, emphasizing the importance of meticulous submissions.

In Conclusion

It's imperative, then, for healthcare entities and physicians to be proactive. By familiarizing themselves with the credentialing checklist, ensuring timely submission of accurate information, and partnering with trusted organizations like Adonis, they can navigate this process more smoothly. Adonis, with its wealth of experience and dedication to precision, provides an edge in sidestepping common pitfalls and streamlining the credentialing journey for its clients.

To learn more about how Adonis can help you as a healthcare provider, use the scheduling link below to set up a quick demo.

Ready to reach your
revenue potential?
Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.
By clicking “Accept All Cookies”, you agree to the storing of cookies on your device to enhance site navigation, analyze site usage, and assist in our marketing efforts. View our for more information.