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The Essentials of Effective Provider Credentialing

Medical credentialing verifies that nurses and doctors are adequately trained, certified, and have the necessary professional experience to deliver healthcare services to patients. It is a critical component of maintaining high standards of safety in the medical profession.

One of the first steps in medical credentialing is to make sure the provider has been credentialed and enrolled by insurance payers and the Council for Affordable Quality Healthcare (CAQH).

The provider credentialing procedure might take anywhere from 60 to 120 days on average, so prepare ahead of time. One error during the credentialing process might cause a delay, which typically necessitates restarting the procedure.

The insurance payer will not compensate the provider for services performed if the provider is not properly credentialed or re-credentialed with the insurance company. To make matters even more complicated, you must follow up with insurance payers on a regular basis to ensure that providers are registered in-network when enrollment is open.

Let’s look at the distinction between provider credentialing and enrollment, as well as the key actions you must follow to guarantee an effective credentialing process.

Provider Credentialing

Credentialing ensures that clinicians have the necessary licenses, certificates, and abilities to appropriately care for patients.

Credentialing insurance plans are often known as “getting on insurance panels.” Obtaining a provider’s credentialing can be difficult and time-consuming—there is no one-size-fits-all solution.

While Medicare, DME (Durable Medical Equipment), and Medicaid providers can be credentialed through their own online portals, the majority of insurance take help from the best medical billing companies.

Furthermore, most commercial insurance payers need re-certification every few years. Re-validation is required by Medicare every five years, DMEPOS suppliers after three years, and certain states need Medicaid re-credentialing yearly.

If you charge an insurance payer but the provider is not credentialed with the payer, your claims will be refused. When an insurance company declines a claim, most of them impose time constraints on resubmitting the claim. If a patient has secondary insurance, you may face even more complications since the longer you delay, the less likely you are to recover the maximum (or any) amount from the insurance payer.

CAQH Proview

Except for Medicare and Medicaid, the CAQH ProView is used in the credentialing process by the majority of medical and vision programs.

CAQH Proview is a credentialing system that allows ophthalmologists, optometrists, and other healthcare practitioners to submit provider data into a secure central database. CAQH collects information on the provider and makes it available to third-party payers.

Registration with CAQH Proview is free for providers. However, before the provider may submit their information into CAQH Proview. The insurance company must tell CAQH in order for CAQH to ask the provider to join CAQH in order for CAQH to build, update, and maintain their directory information.

Provider Enrollment

Actively enroll providers in both commercial and government health insurance plans, enabling them to receive compensation for services provided to patients. For example, if you have successfully enrolled with the insurance plan, the provider is termed “in-network.

Pro Tip for Enrolling in Medicare Providers: For instructions on how to access the PECOS (Provider Enrollment, Chain, and Ownership System) Medicare enrollment management system, become a Medicare provider or supplier. Find your taxonomy code, renew your enrollment, order and certify, enroll as a DMEPOS supplier, and more. Visit the Medicare enrollment and certification website.

Critical Steps for Credentialing a Provider

  • Make a list of everything you’ll need for provider credentialing applications, including professional licenses, employment history (curriculum vitae or résumé), certificates, malpractice insurance certificates, references, practice ownership data, W-9, background checks, bank records, and more.
  • Obtain the provider’s NPI, Federal Tax ID, and Practice EIN (these must match the information on the W-9 form).
  • Obtain the provider’s CAQH ID and register them with CAQH. Ascertain that CAQH has a current W-9 and malpractice certificate for the provider. Confirm that your work and education dates are in the “month/year” format. CAQH will reject your application if you do not include valid dates. CAQH will also send an email to the provider every quarter to “re-attest” that the information in the profile is up to date—always respond promptly.
  • Confirm if you require the provider’s original handwritten signature to process the credentialing request.
  •  Fill out and submit a series of applications to each insurance company.
  • Always get a “reference number” from the insurance payer after completing the initial credentialing evaluation. And capture this in your credentialing tracking records.
  • Follow-up with insurance payers on the progress of the provider’s credentialing application—they are known for not returning phone calls if something is missing from the application. Throughout the credentialing process, keep track of any follow-up calls or online correspondence.
  • Employ the best medical credentialing companies for accurate and reliable credentials.
  • Keep copies of any credentialing applications and contracts you submit, as well as the insurance payer’s credentialing and enrollment letters.
  • Before signing a credentialing contract with an insurance payer, review the fee structure. You may need to request a charge schedule and give your top 20 billing codes to the payer.

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Our End-To-End Best Medical Billing Services consist of certified individuals with over 20 years of experience in medical billing, information technology, and business consulting. Our leadership team of billers and coders has worked with various hospitals, medical practices of all types, laboratories, and individual physicians throughout the last decade.

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