Credentialing for Physicians 101: What They Need to Know?

In the realm of healthcare, credentialing stands as a cornerstone for both patient care and the seamless function of medical establishments. But many patients wonder, what is credentialing in healthcare? And why is credentialing so important? This article will deep dive into why credentialing for medical providers is so crucial.

What is Physician Credentialing?

So, to start at the beginning, what is physician credentialing? 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. While credentialing for doctors is incredibly important, the physician credentialing process can be intricate and time consuming.

What Are Credentialing Requirements?

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.

AMA Credentials

One type of credentialing for physicians is AMA credentialing. The American Medical Association (AMA) verifies a physician's education, training, and experience to ensure they are qualified to perform services. Providers can receive AMA credentials and have their profile listed on the American Medical Association website so that healthcare organizations can confirm their qualifications.

What does a Hospital Credentialing Process Look Like?

The physician credentialing process within hospital systems is a complex system. Typically, the process starts when physicians submit their applications to the credentialing specialists on staff at the hospital. From there, the specialist and healthcare system will conduct primary source verification and brings their findings to a credentialing committee at the hospital. If their application is approved by the credentialing committee, it is sent to a medical executive committee. If the application is approved by them, it then is sent to the Board of Directors, who will grant final approval on the application.

What's the Difference Between Credentialing and Privileging?

This is a common question, since they are similar processes, many patients wonder about the difference between credentialing vs. privileging when it comes to their healthcare providers. While credentialing involves the verification that providers have the proper license and documentation to provide services, privileging ensures that the provider has proved that they are capable of the skills necessary to perform that service.

Group vs. Individual Credentialing

When it comes to credentialing, there are a few options: you can credential your providers as individuals, or, you can credential your entire practice as one group. The process of group vs. individual credentialing is quite similar — both require applications and documentation from each provider to be submitted for review. The main difference here is that when providers are credentialed individually, they have more freedom to move to different practices. Individually credentialed practitioners are accepted by insurance companies regardless of which practice they work with. If your providers are credentialed as a group, they cannot take that credential with them if they leave. The benefit here is that it increases stickiness and employee retention, and practices aren't paying for credentials for providers who then leave.

A third option offered by some insurance companies is for providers to be credentialed individually, but connected to a practices' tax ID number.

What is The Role of Credentialing in Medical Billing?

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.

Why Does Credentialing Take So Long?

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.

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