Physician Credentialing Services – A Complete Guide

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physician credentialing

When an individual needs medical care, they would want to see a highly qualified and competent physician to address their healthcare needs. After all, no patient would entrust their health and wellbeing with a medical practitioner who isn’t certified. Hence, the need for physician credentialing arises, which allows patients to be confident in their healthcare provider’s skills and puts them at ease with the knowledge that they are in the best hands possible.

In a perfect world, physicians would be able to treat patients instantly after completing their training. However, in actual, physicians have to undergo a cumbersome process of physician credentialing to ensure that they meet the standards of quality medical care set out across the country.

Using thorough data collection, source verification, and panel review processes, physician credentialing provides patients with a guarantee of their healthcare provider’s expertise and merit. In a world where most patients pay their medical expenses through insurance, credentialing, although cumbersome, is also vital to the success of every healthcare practice as it allows practitioners to join insurance networks.

What is Physician Credentialing?

Long before a physician can start seeing patients, they are legally required to undergo a comprehensive process of verification of their professional records. These include their identity, education, work history, board certifications, and training. This process is called physician credentialing.

The Credentials Verification Organization (CVO) is responsible for contacting every relevant organization and institute in order to verify the physician’s professional records. It is one of the first steps towards practicing medicine for a physician which is taken to safeguard the patient’s health and their best interests. Physician credentialing also plays an essential role in enrolling the practitioner into an insurer’s network so that they may be reimbursed for the services they provide. After the physician’s credentials are verified, the CVO grants the practitioner the approval to perform medical procedures based on their demonstration of competency – a process termed privileging.

Challenges of Physician Credentialing

While undergoing the medical credentialing process, there are several potential challenges a physician might face that could lead to unwanted consequences. In fact, issues with physician credentialing is one of the most significant issues with compliance for healthcare practices. Errors or inefficiency in the practitioner credentialing process can ultimately cost a practitioner their license to practice, which could also be detrimental to the reputation of the organization they are working for. A well-managed credentialing system is the best way to avoid legal and financial complications in any healthcare practice.

In any medical practice, physician credentialing needs to be done with painstaking meticulousness and precision, which requires a qualified and experienced team to do it. There are several requirements and legalities that need to be taken care of that vary based on your state and the accrediting authority. If medical credentialing isn’t done on time, it could prove to be one of the biggest disruptions in your practice’s revenue cycle. However, the process itself is quite long and takes around 90-120 days before practicing privileges may be granted to a physician. This is because the process entails the collection of a long list of documents which then have to be verified from several different issuing authorities followed by an extensive panel review.

Additionally, medical credentialing isn’t a one-time process. It is a cyclical process that needs to be revisited regularly every 2-3 years to re-evaluate the physician’s records to make sure they are still up to date and to confirm the physician’s fitness to remain in the network. With so many challenges associated with the credentialing process, it is an excellent idea to outsource this cumbersome task to a third-party physician credentialing service that can handle the process of credentialing seamlessly for you while you focus on what is important – providing the best care possible to your patients.

How to Ensure the Credentialing Process Runs Smoothly

Credentialing can seem like an interminable task but following these few guidelines can help grease the parts of the process.

Here are these guidelines:

  • Make sure that the physician provides all necessary information required and that there are no inaccuracies or discrepancies. If any information isn’t available, provide an explanation as to why.
  • Ask the candidates to start the credentialing process as early as possible, long before the physician is expected to start seeing patients.
  • Communicate to the candidates what documents and information are required.
  • Make sure all credentialing information is attested.
  • Use automated tools such as proprietary software and electronic tracking programs to collect the physician’s data and to track the credentialing progress of every practitioner.
  • Know which payers contribute the most to your revenue and prioritize the credentialing to complete those payers’ processes first.
  • Investigate any malpractice claims against your healthcare providers.
  • Understand the rules and regulations of physician credentialing in your state.

Documents Required For Credentialing

When applying for a practicing position, physicians are required to fill out long and extensive credentialing applications. This requires submitting several documents and a lot of information that needs to be verified through their primary sources. To help facilitate the process, it is always a good idea to provide the candidates a list of the documentation required for their credentialing.

This should include the candidate’s:

  • Driver’s license;
  • Social security number;
  • Educational diplomas;
  • Training history (residency, internship, and fellowship certifications);
  • Clinical privilege history including all active state medical licenses;
  • DEA registration;
  • Malpractice liability insurance certificate;
  • Board certifications;
  • Peer references;
  • Clinical performance reviews;
  • History of any malpractice claims; and,
  • Updated CV.

Benefits of Employing a Physician Credentialing Service

If a healthcare practice falls behind in their credentialing, their insurance reimbursements can be disrupted. For practices looking to ensure maximum revenue without affecting the performance of their practice, a physician credentialing service might be exactly what they need. Here is a list of ways outsourcing credentialing can be of benefit to a healthcare practice:

1. High Accuracy and Dedication

Physician credentialing services are dedicated to only focus on your credentialing needs. A third-party service has a team with the right skills, knowledge, and expertise needed to follow certified credentialing practices with round-the-clock availability that could set out your practice from the rest. This ensures compliance and prevents any insurance denials.

2. Short Turnaround

Outsourcing credentialing can reduce the time for the process significantly which can help grow your client volume through more patient referrals and allow you to retrieve your reimbursements much faster. High-quality physician credentialing services also allow you to track each physician’s credentialing and enrollment status.

See Also: Challenges And Opportunities In Medical Practice Compliance Regulations

3. Avoids Paperwork

By allowing a credentialing service to navigate you through the tiresome process of physician credentialing, you can avoid heaps of paperwork and eliminate the burden associated with vast amounts of applications. To ensure smooth enrollment with insurers, the credentialing service also performs any necessary follow-ups with the insurance companies with a speedy system that is fully equipped to follow all standards of a top-notch service.

Bottom Line

Physician credentialing might seem like a tedious and unnecessary task loaded with towers of paperwork, but it’s a crucial process that establishes trust between the physician and the patient and allows the medical practitioner to be reimbursed for the services they offer. Credentialing healthcare professionals also reduces the risk of medical errors caused by incompetent physicians and subsequently protects healthcare organizations from potential lawsuits.

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