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Learn all about Medical Credentialing Services
Modern-day credentialing is far more complex and the process is error-free. We break down the basics of medical credentialing, the major players, benefits, best practices, most common issues and much more.
Medical Credentialing is also known as provider or physician credentialing, it is a detailed process that examines and reviews the health care provider’s qualification and career experience including education, medical certification, training, licenses held and any special certificates to determine if clinical privileges to practice in a particular place can be granted. It must be completed upon the hire or enrollment of a new doctor and regularly afterward to abide by the standards set forth by regulatory and accreditation organizations such as the National Committee for Quality Assurance (NCQA) and The Joint Commission.
Components of Medical Credentialing:
Medical Credentialing may differ state-by-state, however, it usually involves three different processes:
Credentialing: the process of confirming the licensing, qualifications, training and skills of the professional.
Enrollment: the process of requesting participation in a health insurance network as a participating provider. The process includes requesting enrollment, completing the enrollment application, submitting license and insurance copies and finally signing a contract. There may be some additional steps required by specific carriers. Many carriers use the Council for Affordable Quality Healthcare (CAQH) to source various credentialing information from a single trusted location. This means that your carrier may require a current CAQH profile as part of enrollment.
Privileging: the process of a medical professional being granted permission or “privileges” to perform certain specific clinical activities. According to an article published in Medical Staff Legal Advisor, granted privileges are needed in order for physicians to treat patients accurately and safely.
Physician credentialing and privileging is required by the government and accreditation agencies as well as it’s crucial for patient safety. It is also crucial to both developing a practice with a high level of patient care and receiving insurance reimbursement. This process forms the basis of how insurance providers and states determine which providers meet their specific requirements.
Information Required for Credentialing:
It is important to know what information is required from any medical professional to complete the process, before signing up for the Medical credentialing services review. The following information is needed to fill out the Provider Application credentialing paperwork completely.
Personal Information
Education Information
Attestations
Current hospital privileges
Current work status
State of malpractice insurance
Work history
However, credentialing laws and regulations may differ between states. Make sure to research any state-specific rules which may apply to the credentialing application process. To get more specific, the types of verification required for credentialing may include the following:
Personal Information
Citizenship information
Date of birth
Email address
Ethnicity
Gender
Mailing address
Name as written on the license
Phone number
Previous names
Recent photo
Social Security number
Education Information:
Attendance month and year
Certifications/degrees
Institutions
Program Director name
Work Information
CAQH password
Current CV
Current state license copy
Practice address
Practice specialty
Professional liability insurance
Provider NPI number
Work history
Major Players in Provider Credentialing:
There are several organizations which handle the necessary information for primary credentialing. As mentioned, each state has its own licensing program rules, often changed for doctors and for nurses. The following are a few organizations which handle credentialing information:
National Practitioner Data Bank (NPDB): it contains information on the license suspension, revocation or medical malpractice claims, allowing for verification of any negative events in the professional’s past.
The National Clearing Student House: it contains information on education history, allowing for verification.
Federation of State Medical Board (FSMB): it contains compiled information on a medical professional, including certifications, education, states with active licenses and any negative instants from the past.
American Board of Medical Specialties (ABMS): it is a way to check the Board Certification of physicians undergoing review.
The Office of Inspector General (OIG) and the System for Award Management (SAM): these offices are capable of verifying if healthcare providers have any sanctions or exclusions which would inhibit their ability to practice.
Common Issues in Provider credentialing:
Of course, reading and completing the application is just one of the step in the entire process. It also needs to be checked extensively for any errors. The following are some common errors seen with credentialing:
Missing details - includes any missing documentation, required training or filling in of education or training or work gaps.
Incomplete application - includes any part of the application which was not completed, including blank areas, missing support documentation, and incorrect info.
Incomplete training - it occurs when some institutions require further postgraduate training or completion of residency for credentialing criteria, but the applicant has not fulfilled the request.
Poor Organization – a lack of organization can cost an office in appeals and lost reimbursements. Instead, consider outsourcing the credentialing process to a professional in order to keep the office on schedule and ensure no credentialing expires occur.
Medical Credentialing Checklist:
Filling out all the application forms can be daunting. To make the application process more transparent for them, consider including the following in a Medical credentialing Packet:
A completed W9 form
A list of insurance companies to apply with, including links to online applications
Instructions on how to apply for National Provider Identifier (NPI) and CAQH numbers
National Provider Identifier-2 (NPI-2)
Practice Info: address, phone, fax number
Taxpayer Identification Number (TIN)
Helping medical staff or candidates with the process, by providing the right tools and information to make the journey smoother, will both support and help them to complete the process.