Provider credentialing is an important aspect of any healthcare facility. Whether you’re a provider or an administrator, it’s crucial that you understand what provider credentialing is, how the process works, and how it can significantly impact your facility’s bottom line.
This guide gives simple answers to the most common questions that providers and administrators ask about the complex credentialing process.
What is Provider Credentialing?
Provider credentialing is the process through which an insurance company judges the qualifications and competence of a healthcare provider. Before you can be reimbursed by a patient’s health insurance company for the services you provide, you first need to be credentialed by that insurance company and pass their credentialing requirements.
Once a healthcare provider is credentialed by an insurance company, they join that company’s insurance panel. As a professional provider, getting on an insurance panel is how you get listed as an in-network provider and are able to treat patients who carry that insurance health plan. Joining insurance panels can greatly benefit your practice by expanding the pool of potential patients you can treat and giving a sense of legitimacy to your organization.
Provider credentialing is also common referred to by the following names:
- Physician credentialing
- Medical credentialing
- Doctor credentialing
- Insurance credentialing
How Can I Get Credentialed?
The provider credentialing application process requires documentation, and lots of it. Healthcare providers give the insurance company access to relevant records, reports, certifications, identifications, and more. The insurance company or insurance panel then reviews these documents to assess whether or not the participating provider is fit to provide patient care services to its clients. If the insurance company deems the provider qualified and competent, they award a credential.
Let’s take a closer look at the process:
- Step 1: Gathering documents – Every insurance company has different requirements, but the most commonly requested documents include medical school diplomas, board certifications, proof of liability insurance, professional references, records of any malpractice claims, explanations for any disciplinary actions taken against the provider, hospital affiliations, proof of continued medical education, tax documents, and more.
- Step 2: Verification – Once the provider compiles all of this information, the insurance company has to verify that it is all true and up to date, and that nothing is missing. The insurance company typically reaches out directly to licensing boards, universities, former employers and so on to verify the provider’s qualifications. Some insurance companies automate this process, using software to complete these background checks.
- Step 3: Receiving the credential – Steps 1 and 2 of the provider credentialing process can take many months to complete. If even a small amount of the information is inaccurate or missing, the whole process can be delayed indefinitely. However, once the provider’s documentation is all verified, the insurance company awards them a credential and often lists them as an in-network provider on their website.
How Does Credentialing Affect Business?
While providers wait for their documentation to be verified by the insurance company and the credential to finally be awarded, they can’t see patients who carry that insurance. More specifically, patients who carry that insurance will be dissuaded from seeking treatment from out of network providers because those services will not be covered. From the provider’s point of view, they will not be able to receive reimbursement for any services rendered.
Therefore, credentialing can have a negative effect on business operation if the process is approached carelessly or done incorrectly. Time spent waiting for delays and issues to be resolved is time that could have been spent generating revenue.
On the other hand, credentialing can be a major benefit to your practice when done correctly. Providers seek to expand their patient base and perform more services because they are often compensated proportionately to how many patients they treat. Being credentialed with an insurance company is like having a built-in advertising network. When you’re listed as a preferred provider on an insurance company’s website, you’ll see more traffic at your office.
What is CAQH?
The Council for Affordable Quality Healthcare, or CAQH, is an organization that has developed a solution to one of the most time-consuming aspects of the provider credentialing process.
Each insurance company provides their own unique credential. Earning a credential with one company does not mean you are qualified to treat patients from every insurer. In the past, credentialing applications were completely different for nearly every single insurance company, which made submitting your documentation to multiple insurers (something most providers do) an agonizing and lengthy process.
Thanks to CAQH, the process isn’t nearly as complicated.
CAQH created a universal application to collect information from providers about their professional backgrounds. Providers can self-report their information to CAQH so that multiple insurance companies can find it all in one place. Thanks to this new innovation, more than 1.4 million providers and hundreds of insurance companies have been able to simplify the provider credentialing process.1
Some of the biggest insurers that use CAQH, including:
- Affinia Health Network
- Blue Shield of California
- ComplexCare Solutions
- Fidelis Care New York
- Kaiser Permanente
- People’s Health
- Tenet Health
- US Vision
- Value Options
Can I Make the Credentialing Process Faster?
Although the provider credentialing process doesn’t come with any shortcuts, there are best practices you can employ to ensure the process doesn’t slow down. Delays can kill your productivity. Here are a few things you can do to avoid them:
- Submit every document that’s requested
- If something doesn’t apply to you, make sure you write “not applicable”
- Don’t skip any questions and answer everything thoroughly
- Use the format that is requested for things like dates and phone numbers
- Make sure your CV is comprehensive and up to date with no gaps in years
- Don’t forget to include a copy of your Controlled Dangerous Substances certificate
Is Credentialing the Same As Privileging?
Whereas credentialing is the process insurance companies use to grant providers the ability to see certain patients, privileging is the process hospitals use to grant providers the ability to perform certain procedures. The credentialing and privileging processes are similar because they both involve assessing the provider’s qualifications.
Hospitals don’t give providers a blanket ability to treat patients. Instead, they grant them specific privileges, so that providers only perform treatments which are:
- Within the provider’s area of expertise
- Safe to do under the material conditions of the facility
To put it simply, a hospital wouldn’t allow a gastroenterologist to perform brain surgery. Neither would they want the gastroenterologist to perform colonoscopies—despite the provider being adequately trained in that area—if the facility lacks the proper equipment.
Do I Need To Get Credentialed More Than Once?
Many providers choose to get credentialed by several different insurance companies so that they can expand their patient base, deliver more services, and earn more money. Each of those individual insurance companies require their own credentialing process.
Even if you choose to only be credentialed with one insurance company, you will still need to get credentialed more than once. This is because providers need to be re-credentialed at least every three years by law, in order to continue practicing.
How Can I Earn Better Rates From the Insurance Company?
Getting credentialed and joining an insurance panel is often a positive development for healthcare providers. It helps them access a larger network of patients and legitimize their practice. However, the downside is that insurance companies sign providers to contracts that typically don’t have their best interests in mind. Provider contract language may stipulate low reimbursement rates and includes clauses that hurt your business’ bottom line.
Luckily, there is a simple solution to healthcare contracting. Healthcents strategizes with providers and negotiates on their behalf with insurance companies. This helps you get better terms in your credentialing contract, manage your business relationships, earn more money with higher reimbursement rates, and focus on delivering great care to your patients.
Healthcents has been a resource of healthcare contracting insights for more than 25 years. Contact Healthcents today to start signing better contracts and receiving higher returns on your insurance partnerships.
- Smartsheet. Everything You Need to Know About Healthcare Provider Credentialing. https://www.smartsheet.com/medical-provider-credentialing-guide
- CAQH. CAQH ProView List of Participating Organizations. https://www.caqh.org/solutions/caqh-proview-list-participating-organizations
- Thriveworks. Provider Credentialing. https://thriveworks.com/provider-credentialing-insurance-panels/
- STD TAC. Provider Credentialing. Overview and Checklist. http://stdtac.org/wp-content/uploads/2016/05/Provider-Credientialing_STDTAC-1.pdf