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Reimbursement and Practice Management

Provider Credentialing: Steps for Success

Provider credentialing is a verification of your experience, expertise, interest and willingness to provide medical care. Without successful credentialing, provider reimbursement for medical services can be delayed and, even, denied.

In this article, you will learn how to:

  • Determine effective steps to gather necessary credentialing data from physicians as they join the practice
  • List affordable options for physician practices to effectively manage credentialing data
  • Create sustainable workflows and staffing resources for the ongoing maintenance and management of physician credentialing information

Provider credentialing is more than just another form to fill out or a minor nuisance; it’s a complex, ongoing process and a critically important one at that. Without successful credentialing, provider reimbursement for medical services can be delayed and, even, denied. Given its many steps, critical deadlines and lurking uncertainties, provider credentialing is business critical for your practice.

Credentialing, in general terms, is a verification of your experience, expertise, interest and willingness to provide medical care. In broad terms, credentialing encompasses obtaining hospital or facility privileges, as well as successfully enrolling in health plans as a participating provider. Even after submitting the myriad documents and forms to a variety of third parties to verify your credentials after joining a practice, don’t think that you are done. Even though most facilities and health plans do not require a full re-hashing of the credentialing process, most oblige you to submit annual updates. In other words, credentialing doesn’t stop after the initial forms are submitted. You’ll find that the process consumes hours and hours each year, particularly if you’ve adopted an inefficient process.

Although a growing number of payers use the CAQH Universal Provider Datasource® and credentialing software can reduce the paperwork, most practices still manage this information manually or on electronic databases that do not “talk” to other computer systems. The process is far from flawless and an increasing amount of practice staff time is spent researching, responding and maintaining credentialing-related files for providers.

A New England Journal of Medicine editorial in November 2012 claimed that a coordinated national system of credentialing would save providers nearly $1 billion in administrative costs.

“Credentialing and other systems that are used to establish contracts between providers and health plans are riddled with redundancy, with many organizations collecting virtually identical information. The typical physician spends more than three hours annually submitting nearly 18 different credentialing forms with staff spending an additional 20 hours,” the authors reveal.

Not only does completing forms take longer as the volume of required elements increases, but payers are spending more time to process credentialing paperwork. Unless you are willing to work in a cash-only medical practice and forego all privileges at hospitals and other facilities, there’s not much you can do about the number of credentialing requests or the volume of data requested. What you can do, however, is handle your part of the process more efficiently.

Follow these steps to ensure that you and your staff do not get mired in the credentialing process.

Start early. Don’t expect a swift credentialing process. You need to plan months ahead, especially when a new physician is joining your practice – or you are a newly recruited associate. Indeed, many practices request the elements needed for credentialing at the same time that they send an offer of employment letter to a new physician. Given that it can take many weeks for payers and other organizations to process their own credentialing paperwork, a physician joining your practice who ignores or overlooks your request for this information presents a big financial problem – they cannot bill for their services. Consider tying a new physician’s start date – or initial paycheck – to the successful gathering, submission and signing of key documents. Even if you outsource credentialing, you’ll still need an internal person to doggedly pursue the process – and this person must be persistent to the point of traveling to a physician’s home to get a copy of the medical school diploma off the wall, or escorting the physician to a bank to have a document notarized, if necessary.

Develop a sustainable process. While the initial submission of credentialing forms may leave you exhausted, it’s vital to ensure that there is a workflow that maintains all required forms and documentation because re-credentialing is always just around the corner. Assuming that you do not have the resources to support several full-time credentialing staff, there are three basic options for managing this workflow; which one you select depends on the availability of internal resources – namely, staff and money – or the lack thereof. One option is to formulate a spreadsheet of payers, hospitals and other third parties that require updates, and record the requirements for submissions and deadlines. Assign an employee to monitor the process and empower him or her to take appropriate action to get forms signed and necessary data gathered. Alternately, you can purchase or lease credentialing software, or outsource the process altogether to one of many vendors that specialize in credentialing. Regardless of your choice, be sure to monitor the efficacy and effectiveness of the process so you know you are getting your money’s worth.

Recognize key success factors. Complete the CAQH Universal Provider Datasource®, which is the most widely accepted universal credentialing database. On this form or the many others you’ll find that require completion, avoid the temptation to leave any of the data entry boxes blank. With information missing, that form will eventually be rejected. Because these decisions can take months, you’ll have a lot of catch-up work to do in a very short time. Complete every required element, and attach all requested documentation. Avoid multiple trips to the notary public by paying several staff members to become notaries; it’s a simple process that saves an extraordinary amount of time during the credentialing process. And, never try to estimate dates and other critical data from memory.

Determine what steps to take in the interim. It’s long been a myth that it’s perfectly acceptable to bill under another physicians’ identification as you await the results of the credentialing process. This protocol, however, may lend itself to big legal problems if adverse event occurs – the name listed on the medical claims will not be the actual rendering physician. The protocol of billing under another physician while awaiting a credentialing decision might even be expressly prohibited in your contract with a health plan. One plan commonly endorsed by payers is to use a –Q6 modifier, billing the new physician as a locum tenens. For more information, see the CMS Internet Only Manual 100-04 Chapter 1 Section 30.2.11 The wisest course of action is to learn what the payer requires for credentialing, and follow those instructions precisely.

A useful indicator of a smooth-running credentialing process is the track record of denials and adjustments taken during the billing process related to credentialing. Assuming that you already require your staff to accurately record the reason for each denied or adjusted claim, ask your business office manager to report the total number of claims denied, as well as the number of accounts written off, due to incomplete credentialing.

Credentialing can be a maddening and time-consuming (therefore, costly) administrative process, but you will not be paid until you are fully enrolled and credentialed by your participating health plans. And you can’t expect to attract many patients if you don’t have admitting privileges. In order to keep your office running smoothly, it’s vital to prioritize the credentialing process in your practice.

Pearl 9/30/13

Required Re-Cred-Fo-Mation

Data typically sought for re-credentialing of physicians include: professional liability claims settlement history, current Drug Enforcement Administration (DEA) certification, current state medical license, proof of education and training, work history, National Practitioner Data Bank (NPDB) report, board eligibility/certification verification, specialty verification, and sanctions..


Pearl 9/24/13

ED: Effective Date

In 2009, the Centers for Medicare and Medicaid Services (CMS) changed its requirement for retroactively paying physicians for charges submitted for patients seen before the finalization of the Medicare credentialing process. Once willing to pay these claims for more than two years before the physician was credentialed, today CMS pays physicians only for the 30-day period immediately prior to the billing effective date. The effective date is the later of the date the physician filed an application that the Medicare contractor ultimately approves or the date the physician began furnishing services at a new practice location.


Pearl 9/17/13

Get UPD – Universal Provider Datasource®

The Council for Affordable Quality Healthcare (CAQH), a nonprofit alliance representing health plans, networks and industry trade associations, has created the Universal Provider Datasource. This online form collects and stores all of the provider information necessary for credentialing by CAQH alliance members. More than 700 leading health plans, hospitals, and healthcare organizations take part in the datasource project.


Pearl 09/10/13

Quick Credentials

If you are frustrated by delays in the credentialing process, the Health Net settlement agreement and Blue Cross Blue Shield settlement agreement reached with the AMA include a requirement that new physician group members be credentialed within 90 days of the receipt of their application, and physicians can commence the enrollment process prior to employment.

Pearl 09/03/13

Beyond Credentialing

Don’t bifurcate the credentialing process from contract negotiations. If you are new to practice, or expanding your practice to include participation with a new payer, recognize that you may need to do more than just send in credentialing forms. The most effective business strategy is to first ensure that you have settled upon a satisfactory contract. Just signing on the dotted line and submitting your paperwork is apt to bring you only the payer’s standard rate, which is likely lower than your expectations.

United States