Credentialing is the collection and verification of a provider’s professional credentials. This includes their education, medical training, licensure, and work experience.

A provider must go through credentialing with insurance companies in order to be reimbursed for services provided. This process includes submitting an application to the insurance companies, which then verify, process, and ideally approve it. A similar credentialing process also takes place in order for a provider to be granted privileges at a health care facility.

CREDENTIALING VS. CONTRACTING

Credentialing and contracting are oftentimes used synonymously, but are technically two separate processes. A provider or group becomes an in-network provider, or preferred provider, through contracting. The contract outlines the conditions and obligations of each party, as well as a fee schedule, which lays out what the payer will reimburse the group for services based on CPT code.

As part of that group contract, the insurance company also requires credentialing the individual providers.

WHY IS CREDENTIALING IMPORTANT?

1. Patient safety. Credentialing verifies that medical providers are properly trained and certified and have the required professional experience to care for patients. Providers without these characteristics have an increased risk of causing medical errors.

2. Reimbursement from insurance companies. Errors or inconsistencies in credentialing can cost thousands of dollars and interrupt payments. Also, prompt submission of credentialing applications and documentation ensures that a new provider can actually begin providing services on their anticipated start date.

3. Credibility. Credentialing enhances the reputation of a provider or group in the eyes of the health care community and the patients receiving or searching for care.

4. Peace of Mind. Patients place their trust, and their lives, with their health care providers. Knowing their providers hold the required credentials and education in order to care for them is extremely important.

THE CREDENTIALING PROCESS

The credentialing process starts with preparation: gathering everything needed to complete the credentialing application. The application is then completed with extreme attention to detail and accuracy. Once the application is submitted, the insurance company or facility reviews it and submits requests for primary source verification to check for accuracy and legitimacy of documentation. The application may undergo quality review, perhaps by a board, for final approval. Upon approval, the provider is notified, granting them the opportunity to bill that insurance or provide medical services in that facility. The cycle doesn’t end there - providers are recredentialed every two to five years.

PAIN POINTS

Credentialing and contracting are complex and tedious, which is why it is critical to ensure you’re entrusting an expert to complete the process to prevent any errors on the application.

An additional pain point is gathering and maintaining provider credentials. Many providers organize this information using a combination of spreadsheets, checklists, and file folders. A provider must also maintain current documents such as licensure, DEA, professional liability insurance, etc. which they must renew every few years. Credentialing ensures currency of these items.

Finally, there is pressure to have providers ready to go for their projected start date. That is why it is important to get started on credentialing as soon as possible. It takes anywhere from 30 to 180 days to fully credential a provider. Calling the insurance payer regularly to check the status of the application shortens the timeline.

HOW CAN TECHNOLOGY HELP?

Technology can vastly improve the Credentialing process by making it easier to manage provider data and shortening credentialing timelines.

Spreadsheets, file folders, and emails work, but accuracy, currency, and efficiency are all at risk. Having a centralized portal where documentation is easily submitted, signed, and tracked is extremely helpful. Incorporating reminders for both missing items and items approaching renewal is key.

Recording when you’ve gathered all of the data needed, when an application is submitted, and setting recall dates with the different payers is key to staying on track. It is important to set reminders to follow up with the payers and check the status of the application to ensure they have everything they need to move forward in the approval process.

THE BIG PICTURE

Technology improves credentialing and benefits medical providers by saving providers and their administrators time. It reduces the stress that goes along with maintaining credentials and managing all of the applications. Technology supports the revenue cycle by allowing providers to start on or near their start date and therefore accept reimbursement. And last but not least, credentialing ensures that providers are current and competent in providing care to patients. Using technology in credentialing eases the maintenance and management of provider data so that it remains accurate and current. In turn, providers can focus on what matters most - caring for their patients.

pMD partners with providers to lift the administrative burden of credentialing so that more time can be dedicated to patient care. As a trusted partner, pMD takes a holistic approach to knowing its clients and their intricacies, a critical component in effective credentialing. Look to pMD to help support your credentialing, maximize reimbursements, and give you more time with your patients.