Medical Provider Enrollment and Insurance Credentialing Services

What is Medical Credentialing?

Medical Credentialing refers to the process of reviewing a healthcare provider’s qualifications including education, training and residency period, licenses as well as other important career history. The important thing with medical credentialing is that it has to be done just before a provider is hired as the healthcare organization which is going to be associated with a new practitioner needs him/her to be credentialed. It is carried out to maintain standards of quality within the medical community and can be performed at regular intervals to meet the regulatory and statutory standards of accrediting organizations like The Centre for Medicare and Medicaid Services (CMS), The Joint Commission (TJC) and The National Committee of Quality Assurance (NCQA). It usually includes two steps which are credentialing and privilege with credentialing involving verification of competency, education, training, license and work experience and privilege involving granting of approval to a medical practitioner to perform certain procedures as per their skill-set and competency.

The real challenge with getting practitioners credentialed both for medical clinics as well as healthcare institutions is the tedious and time consuming task of collecting, compiling and verifying all the different types of documents from various sources to complete the process of credentialing. This is why healthcare institutions choose companies like Capline Dental Services who have a team of experts at their disposal to immediately initiate the process and see it out till the end thereby producing the desired results in a short span of time. We only require the application with medical practioner’s data once as with the help of advanced softwares we are able to store, verify and format the information to use it as and when the need arises. We also archive the final report and notify you about the medical credentialing date.

What Are the Steps Involved in Medical Credentialing?

Application Gathering and Evaluation:

The first step is to gather all the correct information from the practitioner and complete the required documentation before evaluating it for any potential red flags.

Primary Source Verification:

The second step is to verify the information provided by the practitioner from primary sources like past hospitals he/she has worked at as well as the institutions they have obtained their certificates and licenses from.

Verification with Insurance Payers:

The third step is to verify the practitioner information with the insurance payers as well as update any missing or incorrect information in the database.

Follow Ups:

The fourth step is to conduct routine follow ups for submitted credentialing requests.

In addition to the above mentioned steps we also help with data entry, capturing, labeling and linking data with the credentialing database. The responsibility of updating provider information as per procedures and policies plus maintaining CAQH profile is also fulfilled by us. By performing these duties diligently we are able to ensure that the medical practitioner you hire is verified and truthful about his/her history as well as has the necessary skill-set to perform his role.

What Is the Information Required for Credentialing?

To ensure credentialing accuracy it is important to provide the below mentioned information:

Proof of Identity
- Gender
- Mailing address
- Phone number
- Previous names
- Recent photo
- Date of birth
- Email address
- Ethnicity
- Name as written on license
- Social security number
- Citizenship information
Training and Education Proofs
- Certifications/degrees
- Institutions name and address
- Head director’s name and contact number
Work Information
- Copy of current licenses
- Hospital affiliations past and current
- Professional certificates
- Claims history
Insurance Information
- Current certificate of insurance
- List of open, pending, settled, dismissed and closed cases

Credentialing Challenges That Can Slow Down Your Business

Low Profitability

Due to hospital practitioners not getting credentialed on time patients need to delay treatments which in turn can reduce the profitability of the healthcare institution or clinic.

Due date expiry

In the case of credentialing it is a common occurrence that the due date can get missed if follow ups are not sent in a timely manner.

Manual Process

A lot of practices still rely on the manual process of credentialing which is very time-consuming and tedious.

High number of errors

Companies that are using paper based systems make more errors that the ones using digital systems.

Poor Data Management

Data Management of each and every piece of information is crucial for your practice which is why we offer efficient management of data with adequate storage and all round efficiency.

Non-Compliance

Non-compliance is another area of credentialing which can result in delays in credentialing.This is why it is essential to be associated with companies who follow proper compliance.

Documents Required For Credentialing

DEA
Updated Resume (please mention the month and year of start and completion of the course/experience)
Liability Insurance Certificate Copy
License
Passport (If not a US citizen)
Visa (If not a US citizen)
SSN
Driving License
Diploma Certificate
Specialty Certificate(If you are a Specialist)
Anesthesia/Nitrous Certificate
Copy of Void check (if you want to opt for EFT)

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How Outsourcing Medical Credentialing
Services Can Help You Overcome These Challenges

Medical Credentialing requires coordination between medical practitioner, insurance carrier and healthcare provider. Since all of them are quite occupied and need someone to follow up to give the right information within the required period of time, using a credentialing company saves both time and money. Capline provides the medical practitioner with the credentialing application which when submitted is reviewed by our team of experts. They then reach to the medical practitioner for any proof that they have missed out on as well as check the valid documentation for information given in the application. They also attach important things like claims history, primary source verification and background screen results to fast-track the process of getting credentialed. Once the application is submitted to the healthcare provider they review the information submitted to them. They really need to be thorough as the same information about malpractice insurance, medical license, schooling information as well as documentation pertaining to background checks is verified by the insurance company as well to ensure that the providers meets the standards set out by them.

By Outsourcing Medical Credentialing Services You Get

Faster application processing with no incomplete applications

Savings in term of time and money and increase focus on patient care

No paperwork troubles arising out of poor organization

Decreased overhead costs

At Capline services, we also help you with provider enrollment and becoming an in-network provider to ensure faster reimbursements. Every medical practitioner wants to become an in-network provider with insurance carriers as it allows them quick claim settlements for different patients. However, it can take up to 3-4 months to file the necessary paperwork, coordinate with credentialing departments of insurance companies as well as file the right supplementary documentation. We are here to make it easier for you.

Re-credentialing And Everything You Need To Know About It

Re-credentialing involves the provider repeating the process of credentialing. The medical boards of hospitals require the process of re-credentialing to take place which means every medical practitioner may be up for re-credentialing every three years. The purpose of credentialing is to re-evaluate the skills and history of a practitioner in order to ensure that they are operating within the established medical standards. Moreover, if providers do not complete the re-credentialing process within the given deadline, their credentials are suspended thereby preventing them from practicing medicine till the time they are credentialing once again. We at Capline services have a team of experts who can help you to get re-credentialed so that you can keep practicing like you want. We also notify you of expired documents and help maintain your CAQH profile.

Frequently Asked Questions About Medical Credentialing

1) Why Is Credentialing Important?

Credentialing is important for each and every dentist as it helps state and insurance agencies determine whether you are high quality medical practitioner or not. At the same time, the amount of patients you will get largely determined by you being credentialed as they will only be able to use their insurance if you are.
2) Who Gets Credentialed?

Usually every hospital and clinic gets each and every member of their staff credentialed who is individually responsible for patient care. This includes physicians, dentists, certified nurse midwives, podiatrists, nurse practitioners, physician assistants, certified registered nurse anesthetists and psychologists.
3) Can Any Medical Practitioner Work Before Completing The Credentialing Process?

No, medical practitioners who have not completed the credentialing process are not allowed to work and if found working can be punished as per the state and federal law.
4) What Is The Joint Commission And Why Is It Important?

The Joint Commission is an accrediting organization which aims to improve the quality and safety of care provided to the public. It is important to outsource credentialing services to companies who comply with all the standards set by the Joint Commission.
5) How Will I Know That I Need To Get Re-Credentialed?

Usually you will get an email in your inbox telling you that you are up for re-credentialing which happens between every 3-4 years. However, if you have missed that don’t worry especially if you have outsourced credentialing services to a good company like Capline services as they will remind you as well as get it done if they have all the information with them.

What is Medical Credentialing?

What Are the Steps Involved in Medical Credentialing?

What Is the Information Required for Credentialing?

To ensure credentialing accuracy it is important to provide the below mentioned information: