A credential provider gets more patients because payers send them referrals. Credentialing makes patients feel confident about their provider. It also helps doctors grow their business. Doctors need to enroll with the payer’s network and get permission to treat patients in the payer’s plans. This is called provider credentialing.
What is Provider Credentialing?
Provider credentialing is a process to check if a doctor meets certain requirements. These include having a valid license, not facing serious punishments, having a clean criminal record, being certified by the medical board, and being in good health.
The credentialing process makes sure a doctor can provide proper medical care. It takes around 60 to 120 days for an insurance company to complete this process. This article lists some things that must be done to ensure the credentialing process goes smoothly.
How to Fill Out Credentialing Applications Correctly
A good application is the first step to success in credentialing. You can fill out this application yourself or get help from expert provider credentialing services. An accurate application should have all the details:
- When you started practicing
- Your state license copy
- DEA copy
- Your date of birth and social security number
- NPI number
- Updated CV showing your work history
- Logins for NPPES and CAQH
- Details of any malpractice incidents
- Copies of your degree and diploma certificates
- Copy of your driver’s license
- Name of your group
- GNPI & Tax ID
- Address for practice and billing, along with phone and fax numbers
- A signed W9 form
Why CAQH Database Matters for Doctors
CAQH, short for ‘Council for Affordable Quality Healthcare,’ is a website that stores doctors’ info. Doctors let insurance firms see their info through CAQH, making it easier for them to get the details. Almost all major health insurance companies use CAQH, so doctors need it before joining them.
Getting into CAQH involves three steps:
- Get your CAQH ID (usually in 2-3 days)
- Make a secure username and password
- Fill out the online form and send the needed papers
- Sign the attestation to confirm your application
- Allow insurance companies to see your online form
- Without a completed CAQH form, insurance enrollment is delayed. Plus, you won’t get paid for your work.
Keep checking with the payers regularly
Once you send in the application to become a provider, do not forget to follow up every 5 days. This helps you quickly find mistakes or rejected applications and fix them sooner.
Getting Approved and Getting Paid by Insurance Companies
Once a doctor gets approved by an insurance company, they need to go through another step called Payer Contracting. During this step, the insurance company connects the doctor to its network. The insurance company gives information about how much they will pay and the kinds of plans they have, like HMO and PPO.
When doing Payer Contracting, the doctor should pay attention to:
- Choose an insurance plan that works well for their business.
- Talk about the amount they will get paid for their services and try to make it fair.
- Ask if they can join networks that are not taking in new doctors.
This way, doctors can get into the insurance network, agree on payment, and be part of closed networks if possible.
Keeping physician’s Information Up-to-Date in Insurance Directories
To help patients with accurate information, providers need to keep their contact details current in the provider directory. During insurance directory verification, providers should ensure to include and update the following information:
- Name and education qualifications
- Practice specialty and board certification
- Current legal business name
- Accurate phone number for appointments and queries
Changing Providers in Provider Groups
If a medical group has more than one doctor, they need to regularly update any new doctors or removed ones. This is important to get paid properly. The person in charge of the group should do the following:
Tell about new doctors or mid-level providers who join the group. This is for the contract and the insurance list.
Tell if any doctors are leaving the group. This is for the contract and insurance list too.
Keeping Information Updated
It’s important to keep information up to date. Medical practices need to make sure all details about providers, like payment terms, name, address, tax ID, and new certifications, are current.
Medical technology is advancing rapidly, and healthcare facilities keep growing. The hard work of the medical staff behind the scenes is vital for hospitals to provide quality care. Provider credentialing is crucial for hospitals to run smoothly.
Conclusion
The process of provider credentialing holds several benefits. It helps providers attract more patients through referrals and assures patients of their credibility. Additionally, credentialing supports providers in expanding their businesses. To achieve successful credentialing, physicians need to meet specific criteria, including having an unrestricted license, maintaining a clean disciplinary history, and meeting certification requirements.
FAQs
What’s the contrast between credentialing and contracting?
Are credentialing and contracting alike? No, they’re not the same. Credentialing reviews a doctor’s qualifications, while contracting involves getting contracts with insurance plans.
What’s a credentialing example?
Some of the main examples of the credentials are Educational degrees: doctorates (Ph.D., DrPH, DNS, EdD, DNP), master’s (MSN, MS, MA), bachelor’s (BS, BSN, BA), and associates (AD, ADN). Licensure: RN and LPN are credentials.
What’s system credentialing?
Well, it’s a term for processes that show someone or something meets set standards to do a certain job or role.
What is meant by “lack of credentials”?
It refers to not having the skills or experience needed for a job, or not having official proof of your skills. In today’s world of blogs written by people without official qualifications, there’s a discussion about what counts as journalism.
Why is credential management important?
It is a hub for storing user account info. This makes handling credentials and access easier for IT. Also, it guards security by enforcing rules.
What does a credentialing executive do?
They create and handle goals (KPIs) and dashboards to boost client satisfaction, results, and help staying with rules and regulations. They also make sure processes are the same and workflows are smooth to give services that please customers and save revenue.
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