Did you know that out of every five healthcare service claims filed in the USA, one belongs to an out-of-network provider? Being impaneled with leading insurance companies helps the healthcare providers to improve their revenue cycle. More patients opt for healthcare services that their insurance will cover so that they have lesser out-of-pocket expenditures. Right provider credentialing is the key for healthcare providers to get in the panel of reputed insurance companies.

You might have heard all this information elsewhere too. But what no one tells you is how complicated the process of provider credentialing can be! It is challenging for beginners who are just starting on their own. In this article, we have tried to compile the most frequently asked questions, the tricky issues, and reasons why you should start preparing for provider credentialing if you have not already! Here’s a guide for all beginners.

1.What do you mean by provider credentialing?

Provider credentialing is the process through which the educational qualifications and the clinical competence of the healthcare providers are analyzed and verified. From their medical school certificate to their latest professional training, each document of the provider is collected. Apart from these, the credentialing teams also verify the DEA certificates and other federal requirements.

2.What are the documents needed in provider credentialing?

Collection and verification of several documents of the healthcare provider complete the provider credentialing process. While some primary documents are standard for all, requirements of particular states, local governments, and insurance panels are specific. Here is a list that you will find helpful:

  • Demographic details of the provider
  • Detailed contact information
  • Immunization Records
  • Medical School Diploma
  • Certifications of professional training and residency
  • Fellowship certificates (if any)
  • Federal Tax ID
  • Board certification document (if any)
  • Proof of Continuing Medical Education (CME)
  • Professional Liability Insurance Coverage
  • Any history of malpractice with proper documentation
  • Medicare and Medicaid details

If you are a foreign medical school graduate, you will additionally need the following papers:

  • ECFMG certificate or Fifth Pathway Program details
  • All non-US citizens also need to show a copy of their visa status or permanent resident card, or green card, as applicable.

3.Who performs the credentialing procedure?

Provider credentialing is essential both for the healthcare organizations and the insurance panels. Therefore they perform the procedure separately with certain modifications. Here are some pointers for beginners to note:

Government Payers: 

  • Government payers like The Centers for Medicare and Medicaid Services have enrollment forms on their web portals and document requirements.
  • They perform the credentialing process through their teams to accommodate the providers in their varied plans like Medicare Part A or Part B.

Private Insurance: 

  • Providers can also enroll themselves in the different leading insurance panels like UnitedHealth or Cigna.
  • However, they have limited seats on their panel. The providers should keep an eye out for the openings of their choice.
  • The requirements for the separate plans under the same panel might be different. So you should check them out as well.

Healthcare Organizations:

  • Healthcare organizations have primarily two goals when performing provider credentialing.
  • Firstly, they will verify the provider’s documents to understand if they have the required clinical competence and professional efficiency needed for the role.
  • The same data collected will be used by them to enroll the providers in different insurance panels.
  • The correct documentation will pave the way for timely reimbursements and keep the organization’s revenue cycle strong.

4.What are the different steps of provider credentialing?

Now that you know the stakeholders involved and the documents needed for the process, here is a stepwise guide for you.

  • Prepare a checklist of documents needed by a particular stakeholder.
  • Collect the papers and fill in the credentialing forms.
  • Check for any mistakes that might delay the approval process.
  • Submit the forms with the required documents to the authorities.
  • In the case of insurance carriers, make sure you follow up with them frequently to know the status of your application.

5.How can you choose the right payers for you?

Most healthcare providers want to get in top panels of leading insurance payers. But most of the time, it does not happen as there is a shortage of seats. Here are few tips to get credentialed by the payer networks:

  • If you are looking for Government plans like Medicare and Medicaid, you should submit your application early and without any errors.
  • For private insurance companies, keep a daily tab on the openings of your choice.
  • The same panel might have different plans. So make sure you choose one that fits your needs.
  • Keep an eye out for the local insurance payers as well. There might be a more significant number of patients in a local area who have subscribed to these panels. You do not want to miss them!

6.How can you avoid any delays in credentialing completion?

Provider credentialing is undoubtedly a lengthy and cumbersome task where you need to be cautious about every move you make and every form you fill out. One small mistake can delay this process for too long and harm your cash flow.

  • The credentialing process takes around 90 to 120 days to finish.
  • The key is to start early with your applications so that you have the required time to review your errors.
  • Following up with the insurance payers is a must. So make sure you do that frequently regularly.

7.Is outsourcing provider credentialing a good option?

Yes! Outsourcing is a very effective as well as an economical option for provider credentialing. Outsourcing will give you the following benefits:

  • The leading companies will take the burden of the enormous paperwork off your shoulders and compile them.
  • They will keep an eye out for the insurance panels you wish to be a part of. They can also suggest some suitable options.
  • Their teams will coordinate with the insurance panels regularly to follow up on your application.
  • Some companies use homegrown software solutions to simplify the provider credentialing process. This helps in error-proofing the applications.
  • The returns on investment are high. They will ensure that you are in-network. But you need not invest any time and energy in the entire process.

To know how to choose the best outsourcing partner, you can read the article here.

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