The Importance of Medical Professional Credentialing

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Credentialing is the process by which insurance networks, healthcare organizations, and hospitals obtain and evaluate documentation regarding a medical provider's education, training, work history, licensure, regulatory compliance record, and malpractice history before allowing that provider to participate in a network or treat patients at a hospital or medical facility.

Partnering with insurance carriers is a necessary process for any medical office. Physicians and other professionals must provide a list of verifications to insurance carriers, including Medicare and Medicaid, in order to be eligible for reimbursable expenses.

Types of Verification Required for Credentialing

Professional credentialing verifications may vary by according to the specifications required by individual insurance carriers and medical facilities but may include the following:

  • Provider Enrollment Application
  • State License
  • DEA License
  • Board Certification
  • Education and Training
  • Hospital Affiliation
  • Malpractice Insurance Certificate

Consequences of Not Obtaining Timely Credentialing

Obtaining adequate professional credentialing to partnering insurance carriers and hospitals could take up to six months. A medical office should include one very important rule in their financial policyDo not allow any medical office professional to perform services without proper credentialing.

The results of not obtaining proper credentialing can result in lost revenues. Insurance carriers will not reimburse any medical office that bills for professionals or for services provided by professionals that have not been properly credentialed.

If for some reason you have allowed a professional to perform services before credentialing is complete, some insurance carriers will backdate your reimbursement to cover services provided. However, there is a limit to the timeframe. Taking that risk could cost your medical office thousands of dollars that can never be collected from the insurance payer or the insured.

It is becoming increasingly difficult to get credentials because there are many doctors all trying to practice in the same areas, competing for spaces on an insurance company panel. A panel is a list of approved credentialed doctors, but if there are too many names on the list, the insurance company may deny admission and credentials.

The safest and most financially viable solution is to submit your provider enrollment packet including any required documentation and verification as quickly as possible. The success of your medical office depends on it.

Respond Swiftly to Verification Requests for Work History for Credentialing

The flip side of credentialing is that your medical office and providers should also be good colleagues and respond immediately to any requests for verification of work history or references for physicians being credentialed by insurers. You could be holding up credentialing for those individuals if you don't respond quickly.

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