The credentialing process for physicians is a necessary practice that is extensive and involves a complicated series of steps. The credentialing manager of Anthem for Virginia, Joellen Scheid claims that 85% of credentialing applications miss out on critical information. This prominently insinuates how crucial it is to streamline the steps in provider credentialing to ascertain the efficiency of the process allowing physicians to begin practicing in the shortest time possible.

It goes without saying that practicing medicine is a privilege that comes with many social responsibilities hence, it is essential to make sure that a doctor has proper verified credentials.

Steps to streamline the credentialing process for physicians

The credentialing process has become more exhaustive yet refined in recent times. What seems to be a simple process may become a nightmare of resubmitting applications, fighting enrollment abnegations, and staying on hold, depending on the vacancy of a particular specialty.

Here is what we can do to streamline the credentialing process for doctors.

Encouraging early applications

It is a fact that the credentialing process is a procedure that takes anywhere between three to four months if things go smoothly, and can even extend to six months when requirements are not fulfilled. It gets frustrating for the physician and the healthcare provider as there are delays in network reimbursements unless the contract process is complete.

It is advisable to begin the credentialing process for physicians at least a month or two before the actual commencement dates. It is also preferable that all the qualifications that make a physician eligible for filing a credentialing application must be competent and the required documentation must be complete and accurate.

Given below is a list of common requirements as specified by major leading credentialing organizations, to prevent delays and discrepancies in the future:

  • Degree and certification of practice and training.
  • Completion of the residency program in a designated specialty.
  • National Provider Identification (NPI) number.
  • W-9 Form.
  • Active professional liability (malpractice) insurance.
  • Malpractice history (summary of any pending or settled malpractice cases).
  • Five-year work history (summary in case of work gap longer than six months).
  • Credentialing contact information.
  • Citizenship documents (for providers born outside the U.S.).

Supporting documents may vary with the type of provider enrolling and the State credentialing laws.

Pre-application: Getting on board with insurance companies

It is essential to link up with an insurance company that will simplify the steps for provider credentialing. There is a wide range of companies to choose from, and the providers can research to find the one they want to associate with. Each company will require a different process that will eventually lead up to Council for Affordable Quality Healthcare (CAQH) application. Major insurance companies, like BCBS and Aetna, are in conjunction with the CAQH application.

To save resources and prevent the applications of incompetent physicians from getting processed, this is an important step to shortlist the candidates, by rejecting those who have incomplete requirements. That is because a provider is required to apply to the insurance company first. This application needs to be approved by the insurance company. Only then can it be further linked up to the CAQH portal using the generated access number sent to the provider by the insurance company.

Filling out the CAQH application

As stated, a CAQH profile is a much-needed step not just for now but even when the physician applies for the re-credentialing process years later. A physician cannot directly upload his information on the CAQH portal, he has to be invited by the associated insurance company

There is an option to submit applications in hardcopy. However, it is desirable to use the online portal instead. It is because paper applications are not as secure and can lose vital information when it is being entered manually in the Cloud. The use of Cloud technology ensures a safe and accurate way of sharing and using credentials.

These CAQH applications require all the information, from documentation to certifications and signatures to attestations. Once again, it is endorsed to submit accurate information to prevent delays in the credentialing process.

Using the primary source verification

Verifying the given information by aligning it with the primary source, or issuer is a necessity in the credentialing process for doctors. It is because secondary sources of information, such as the one provided might be inaccurate, unreliable, or exaggerated. This fabrication might be carried out by providers or imposters, to benefit workflow and patient access. The purpose of PSV is to provide an authentic portrait of the physician in the healthcare industry.

The process can be denied or delayed in case of any discrepancy. It can prove to be an expensive outcome, and may result in the start of the process all over again or may even lead to absolute elimination.

Reviewing of credentials by CVO

Validated credentials are further reviewed with the aid of the credentialing committee, within the Credentials Verification organization (CVO) to determine competency and professionalism and make sure that the earlier medical services have been executed in their steps in provider credentialing proficiently.

The application with questionable findings is not processed until the network contacts physicians to provide the desired documents for further verification. If the candidate fails to accomplish that and does not resolve the matter, they cannot get credentialed and might even have to face further investigation compliant with this discrepancy.

If the issues are all positive – such that there is no trouble in the malpractice history, criminal convictions, state sanctions, disciplinary actions then the candidate is permitted to move ahead with the credentialing process.

The contracting phase

Once all credentials are verified, the next step is a contract of participation. The credentialing network has to review and negotiate the reimbursement rates and responsibilities of the physician. When this agreement is established, the network provides the physician with an effective date and provider number to receive the reimbursement of claims.

Here the credentialing process of physicians is finally complete. It assures that the physician is eligible to treat his patients in a safe, high-quality environment that promises trust and excellence in healthcare.

See Also: Medical Coding Audits – The Best Practices

The Bottom Line                         

There is no exception when it comes to the credentialing process for doctors. The main goal is verification accuracy, which requires an inevitable series of steps. All in all, one thing is for sure – provision of complete, eligible, and accurate data is the best way to ensure a smooth, streamlined physician credentialing process!

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