Best Practices in Physician Credentialing

Physician credentialing, the necessary first step in enrolling a medical practice/physician (new or existing) with the insurance carrier, occupies an important place in the healthcare insurance process chain. Effective credentialing processes help in obtaining on-time reimbursements for the medical services rendered and create a financially stable practice.

Physician credentialing is not a one-time effort but requires regular updates to ensure that physicians are re-credentialed and therefore, reimbursed appropriately and on-time for the medical services rendered.

What is Physician Credentialing?

As the name suggests, physician credentialing is the process by which healthcare insurance companies evaluate the physician’s history and practice and verify their documents/paperwork such as educational qualification, work history, training, certificates, licenses, malpractice insurance, etc. After ensuring that the physician meets all the standards of regulatory and accreditation bodies, the physician is said to be credentialed and is absorbed into the insurance company’s provider network.

Physician credentialing has two major benefits that necessitate the process.

  1. Stamp of assurance. With credentials being verified by the health plan, the physician credentialing process establishes trust in the minds of the patients/health plan members, and they can rest assured that their physician is validated by the health plan.
  2. Improved patient flow to the practice. By virtue of being part of a healthcare payer’s network, the physician sees improvement in the number of patients coming to his/her practice.
  3. Improved patient experience. From the hospital/ physician point of view, timely physician credentialing enables them to schedule patients on the assurance that the health plan will reimburse them for the services provided by the physician.
  4. Improved reimbursements and reduced denials. Credentialed physicians are likely to get reimbursed on time. Often, hospitals get their claims denied because the physician brought in to provide a medical service was not credentialed. An iterative process needs to be instituted by the hospitals to ensure that the visiting physicians that a hospital typically utilizes for delivery of medical services, especially in the emergency room, go through effective onboarding and credentialing process.

Physician credentialing, however, is not a simple process. It is a time-taking process that can take anywhere between 3-6 months to be completed. It requires the collection of the physician’s documentation, identification of missing information and documents, primary source verification of all the information provided by the physician, and completion of the data on the health plan’s website. Seamless Physician credentialing processes help payers reduce their cost of credentialing annually besides ensuring that the patients are not kept waiting for care, while physicians get timely reimbursement for the services rendered.

Best Practices Physician Credentialing

Following these best practices in physician credentialing will enable better outcomes for all parties involved.

  1. Create a time-frame and build time into it: As mentioned earlier, physician credentialing is time as well as resource intensive process. Waiting for the last minute could be detrimental to the patient experience and revenue cycle. Whether the practice is new and needs to be credentialed for the first time or an existing practice that needs to be re-credentialed, start the process early and establish a time-frame that makes allowances for unforeseen delays (if any) during the process. For instance, if there are many applications for credentialing, the process may take longer and in turn, cause incessant delays and disrupt patient care and experiences.
  2. Keep documents, licenses, etc. updated: Outdated and incomplete information, documents, licenses, etc. are one of the top causes of delays in the credentialing process, with insurance payers stopping the process mid-way till the updated and/or completed information reaches them. It is critical to ensure that all documents, licenses, malpractice insurances, etc. are complete, continuously updated, properly organized and accessible always. For instance, certifications and insurances are valid only for specified periods and need to be renewed accordingly.
  3. Catalog and Store the documents. As numerous documents are required for physician credentialing, it is imperative that all these documents are cataloged effectively with appropriate indexing.
  4. A Clear understanding of regulatory and payer-specific requirements: The physician credentialing process may differ from payer to payer, specialization to specialization and state to state. It is, therefore, essential to ensure that you are fully aware of the latest and practice-specific regulatory, payer, and other requirements. It is equally important to stay in close contact with the insurance payer after submission to follow up on the process.
  5. Leverage technology and expert services: Several cloud-based providers today offer physician credentialing tools. Additionally, revenue cycle management companies such as Atom Healthcare leverage the power of technology and provide a team of specialists to ensure that the credentialing process is seamless across payers, timely and cost-effective.

With effective management of the credentialing process, physicians can focus their time and efforts on patient care and creating great patient experiences without worrying about getting reimbursed for the services they provide.  


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