What is Credentialing? Inside the Complicated Health Insurance Plan Enrollment Process

The federally-mandated process of vetting medical professionals can be cumbersome for health care organizations. It’s known by several names: payer/payor credentialing, provider enrollment and medical credentialing with many overlapping processes. While its goal is ensuring safe, high-quality medical care, it lacks national standardization and can take valuable time and resources away from health care staff. Below we dive into some credentialing FAQs to help make sense of the process.

What Is Credentialing?

Credentialing is a requirement for most medical professionals working in a health care setting. Physicians, dentists, nurse practitioners, physician’s assistants and other medical professionals must maintain current credentials. These individuals need to remain in good standing with licenses, board certifications, malpractice insurance, etc. But what is payer credentialing? Understanding the credentialing process can help medical providers organize necessary documents and familiarize themselves with the complicated and time-consuming process.

Credentialing is a component of the payer enrollment process that’s intended to verify the competence and expertise of a medical provider. Provider enrollment is a process of requesting for participation in a health insurance network as a participating provider. The provider is responsible for demonstrating that they possess the necessary skills and training to deliver the required level of care to members of a health plan.

Payers establish specific frameworks and guidelines to ensure the necessary level of patient care. They must verify that a medical practice/group is offering the best care and ensuring patient safety by adhering to these standards. Credentialing is a cumbersome, tedious, lengthy process and includes verifying information about education, training, special certificates, work history and other documentation. This process is separate from network contracting, which determines fees and terms.

Why is Credentialing Important?

The merits of medical credentialing do not end with verifying the credentials of providers. Financial incentives are essential. For example, most healthcare organizations cannot receive reimbursements for their offered care from payers, eg Medicaid and Medicare, if they are not credentialed. There are several reasons why credentialing is important.

Protecting Patients

This is the core purpose of medical credentialing. Although the process is complex and tedious, conducting a deep dive into relevant data points is crucial. For example, ongoing monitoring of a practitioner against the Sex Offender and National Abuse Registries, Death Master Files, etc. instills confidence in patients as they feel safe seeking care from their medical professionals and health care organizations.

Prevent Potential Revenue Loss

Insurance payers will not reimburse a medical practice or hospital without credentialing. They must receive in-network participation with those plans for which they wish to render care to its members, eg, state, federal and commercial payers. Newly hired medical professionals must also undergo a rigorous credentialing process prior to submitting claims for reimbursement.

An organization may be subject to fines and civil monetary penalties if it receives reimbursement and the payer later determines that the provider was not credentialed Thus, a healthcare organization must verify that their provider(s) are thoroughly vetted and credentialed before treating patients. There is no standard method as the credentialing process varies payer by payer. Delays or miscommunication during the enrollment/credentialing process can lead to negative impacts on downstream revenue among other costly issues.

What Does the Credentialing Process Entail?

Identifying and Prioritizing Insurers

The first step is to identify a list of health insurance plans for which to enroll providers. Most medical practices work with several different insurance companies and each company has its own methodology when it comes to credentialing. Create a payer matrix to identify and organize the primary information for all your payers to include specific information for enrolling providers. It’s key to know who your top payers are as these plans should be your areas of first focus when enrolling new providers. This should become a centralized ‘go-to’ resource for members of your payer enrollment team.

Gathering Required Data

You will need to gather the data and documents necessary to meet the credentialing requirements of each payer. For instance, provider information may include:

  • Demographic information
  • Proof of license
  • Historical data (eg, work and claims history)
  • Proof of insurance coverage

Credentialing Timelines and Inefficiencies

Depending on the payer, credentialing for a newly contracted provider can be expected to take three to six months from the time of application submission. If a payer determines a provider’s application as being incomplete when submitted, it causes delays in scheduling patients, billing and reimbursement, as well as resources to complete the rework. These delays can cause a negative impact on downstream revenue.

Perform quality cross-checks of information and supporting documentation for accuracy prior to submitting to payers. Be proactive and communicate with payer reps regularly, to ensure your provider(s) is progressing through their credentialing process without deficiencies.

Credentialing can be a complicated process with a lot of room for error. Due to the complexities and time-consuming processes of payer enrollment and credentialing, it is wise to seek qualified professionals to help. Anders Health Care advisors and our partners at Fifth Avenue Healthcare Services can help navigate the intricacies of payer credentialing and help to minimize enrollment turnaround times. Contact an Anders Advisor below to learn more.

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