What Is Physician Credentialing in Healthcare?

14 February 2022
credentialing for physicians

In the healthcare industry, physician credentialing is an important process. It is the process of verifying the credentials including qualifications, licenses, work history and more of the medical practitioner and ensuring their background is clear.

When Does Credentialing Happen?

In the healthcare industry, there are both health care providers and health care/medical centres. Hence, we can classify physician credentialing majorly under 2 buckets – 1. for the medical centre and 2. for the medical provider.

Multiple scenarios for it to happen are as following:

• When a doctor or a healthcare provider is joining or beginning a new practice

• When a doctor switches from one healthcare practice group to another

• While a practitioner or a health care provider is getting enrolled with a new coverage provider

• Periodical re-credentialing by reviewing, verifying, and maintaining their credentials

Why Is Credentialing Important?

Credentialing is the process where the authenticity of the healthcare professionals is validated. It serves as the security gate wherein only qualified professionals are allowed inside. It restricts the admission of unqualified healthcare workers to the healthcare system. It serves as an audit point for their credentials of qualification, work history, malpractices, attestations, etc.

Also, credentialing is very important for the financial income of the healthcare centre. Only by credentialing, the insurance payers will process the payments of the services rendered by the professional at the centre. Hence it is imperative for both the medical practitioner and the medical service centre to be credentialed and get enrolled in the payer’s network.

How Long Does It Take for Credentialing to Complete?

Credentialing process requires an extensive list of information pertaining to the practitioner and the practice to be gathered, submitted, and verified. The process is time-consuming and generally takes about 8-16 weeks for the process to be completed and get credentialed. With incomplete documentation, it may lengthen the process furthermore and may take even up to 6 months.

What Are the Major Challenges in Physician Credentialing?

• Incomplete applications are the major reason for the delay in processing. There could be information that is missing or wrong. Some information like work history, recent attestations etc. could be outdated.

• With credentialing, laws from state to state differ. It is the duty of the healthcare provider to ensure that he/she adheres to the regulations of the respective state he/she is serving. While reciprocity regulations make it a little easier for streamlining, it is still very important to understand the differences between each state’s law and have the credentialing done appropriately.

• It is still required in some cases wherein a physician or a medical centre must get credentialed with every insurance payer individually. In such scenarios, it becomes tedious for them to complete each process separately. With the incorporation of Council of Affordable Quality Healthcare, Inc. (CAQH), a repository of data pertaining to credentialing, many coverage companies use the verified inputs from them to complete credentialing. The provider must update current information in the database to ensure it provides the correct information to the payers.

• As mentioned in scenarios requiring credentialing, a medical practitioner must ger credentialed separately for each of the practices or hospitals he/she is associated with. This can again be time-consuming. Credentialing of a physician at one centre can no longer be used at another centre.

Quick Tips for Physician Credentialing

The following can help you avoid delays and fasten the credentialing process.
• Ensure to initiate the credentialing process immediately when you finalize a new physician to your centre. The more you delay in submitting the application, the more it gets delayed in completing the process and getting credentialed

• Have a checklist to ensure no details are missed along with the application

• Ensure to collect all updated details from the new physician. This will avoid delays due to the production of outdated information

• Ensure to take the help of technology wherever necessary to ease and streamline the entire process

• Stay updated with the current state laws to ensure all relevant details are provided

• Encourage practitioners to update their details regularly in CAQH so that insurance payers find it easy to retrieve information for credentialing

Why Should You Consider Outsourcing Your Credentialing Process?

With physician credentialing being a long process with a lot of paperwork, documentation, verification, and submission, it can be a heavy workload for the medical centres or individual physicians to cater to. By outsourcing the entire process, they can focus more on their medical services and provide better healthcare to patients.

Our physician credentialing services at Business Integrity Services help you stay updated with the current regulations and submit the applications on time without any delays. We ensure to attach all relevant information required for the attestation and provide hassle-free services. We provide end-to-end credentialing services to individual practitioners, hospitals, medical centres, and other medical facilities. Reach out to us for more details and customized solutions.