Every healthcare facility must credential medical professionals and practitioners. Whether you run your practice or are part of a large institution, this process is essential to the operation of your organization. Provider credentialing is a vetting process that checks credentials and certificates for validity. This information is then used to grant privileges at a medical facility.
Getting Started
Healthcare provider credentialing is a process that verifies medical practitioners’ credentials and determines their eligibility to perform certain services. It involves gathering and assessing primary source data, which includes documents such as licensure, academic qualifications, malpractice claims history, and recommendations from other medical professionals. It also requires the review of clinical privilege delineation and payer enrollment. Traditionally, providers were required to apply individually with each insurance company they wanted to work with, which can be time-consuming. Even a single misstep can cause a long delay in the ability to be approved for provider credentials and eventually receive payments from payers. To avoid these problems, consider using a healthcare credentialing service that streamlines the submission and verification process.
Gathering Documents
The medical credentialing process looks at the background and qualifications of healthcare professionals. It includes checking various databases to ensure the medical provider has valid certificates, licenses and education. It also provides that no past reported issues could suggest they cannot competently treat patients. The credentialing process is so important to the reputation of a medical office and the medical practitioners. There have been too many cases of misdiagnosis and poor treatment quality, and that has made patients watchful. It is a good idea for the medical staff to collect all documents and information needed before starting the credentialing process. It will prevent errors that can delay the process. For example, a simple mistake like swapping dates on a resume could delay the process for weeks or months until it is corrected. It can also cause delays in the ability to obtain insurance contracts and reimbursements from payers.
Verifying Documents
As a medical credentialing manager, it’s your job to collect and verify the documentation that healthcare providers provide. This information can be gathered via email, telephone or through software. When it comes to verification, it’s best if written correspondence or faxes are used, as these documents can serve as proof that the necessary steps were taken. Keeping a detailed call record is important when verification is done via phone. It will help prove to the accreditation organization that primary source verification was performed. Laws recommend writing down the name of the individual contacted, their phone number, questions asked and their answers. It’s also a good idea to request copies of the provider’s notarized government-issued identification, criminal background check and OIG status report. It helps ensure the process is completed on time due to missing documents. Lastly, it’s recommended that you start the credentialing process 90 days before the healthcare provider’s anticipated start date.
Presenting Documents
Medical credentialing is essential to a healthcare center’s reputation. After all, a stringent vetting process helps keep only the best and most experienced medical practitioners, nursing homes, and clinics enlisted with insurance companies. It builds patients’ trust in a healthcare facility and elevates the medical personnel’s professionalism. Automation in the medical credentialing process helps reduce mistakes, speed up the application, and make it easier for an insurance company to verify the submitted documentation. It makes it more likely that the healthcare service provider will be able to become a contractor and start serving the insurer’s customers soon. As the number of malpractice cases in the US is a concern, patients are now very watchful when choosing their healthcare service providers. It has led to many hospitals and other healthcare service providers being re-credentialed by insurance companies. It can take time and is inconvenient, so using automation in the medical credentialing process is vital.
