What is Medical Credentialing

WHAT IS MEDICAL CREDENTIALING?

What is Medical Credentialing - Royalty Medical Solutions Desk

Medical Credentialing ensures doctors who are practicing in a given state or city have received all the necessary training and experience to safely and efficiently practice medicine. During the medical credentialing process, there are many factors taken into consideration, including:

    • Education
    • Training
    • Residency
    • Experience
    • Licenses
  • Certifications

During the Medical Credentialing process, malpractice history is also taken into consideration. Each provider will be required to have sufficient coverage and resolved malpractice claims. A medical professional must complete this review of medical credentialing whenever they start at a new practice or change states.

Privileging

Medical credentialing and privileging usually consists of a few different processes: provider credentialing, provider enrollment, and privileging.

Medical Credentialing can be done by the medical network during the provider enrollment process.

Breakdown of Medical Credentialing:

Provider Credentialing – the process of verifying the provider’s skills, training, licensing, qualifications, etc.

Provider Enrollment – the process of enrolling a provider with insurance plans. Encompasses everything in the application process, credentialing process and then contracting.

Privileging – approving providers to perform specific procedures and granting them a specific set of privileges. This is usually done within a Hospital or Healthcare Organization.

Medical credentialing is not only a critical component of developing a practice that delivers the highest level of patient care, it’s essential for insurance reimbursement.

Through the credentialing process, states and insurance networks determine which medical providers meet their requirements.

THINGS TO KNOW ABOUT CREDENTIALING

What do you need to know before signing up for Medical Credentialing in any given state or market?

First, it’s important to know that it takes a while. Medical Credentialing can take anywhere from 120-210 days, depending on the market. Give yourself plenty of time to complete your credentialing. Many will say 90 days, but this is rare nowadays!

Make sure you fill out the application paperwork completely. Missing information, such as work history, current work status, the state of your malpractice insurance, or any current hospital privileges you have, will result in delays. Gaps in work history will hold up the process if there is no explanation given.

Don’t forget your attestations — the paperwork that ensures your forms are accurate and valid. If you must change any information after the application has been completed, you’ll have to rewrite and resubmit your attestation.

When doing Medical Credentialing, several healthcare organizations will use entities such as CAQH to verify your information.

Staying current with relevant organizations, like the Coalition for Affordable Quality Healthcare (CAQH), can help make your credentialing process a little simpler.

Each state has specific Medical Credentialing laws and regulations, so make sure you’re aware of any particular rules that could apply to your situation. If you’re changing states, you will be required to apply under that state. You can not take network status across state lines as they often have different laws and guidelines they abide by.

Successful Medical Credentialing requires you to be very organized.

VERIFICATIONS

Medical Credentialing is important in each state. Several state organizations handle the information necessary for primary Medical Credentialing. Each state runs its own Medical licensing program, and that Medical program will often be broken down further, separating doctors from other clinical specialties.

Agencies such as the National Student Clearing House contains education history, allowing a doctor or nurse’s education to be verified, while the National Practitioner Data Bank (NPDB) holds information on medical malpractices claims, license suspensions or revocations, and other negative events in a professional’s past.

POST CREDENTIALING

Once a provider has completed Medical Credentialing with an insurance company, they enter into an agreement with that insurance company. This agreement will lay out the terms of how to bill and be reimbursed as an in-network medical provider with that insurance company.

While hospitals and larger healthcare organizations often have staff dedicated to managing medical credentialing, many smaller practices must help their clinical staff navigate the medical credentialing process without the benefit of a devoted medical credentialing department.

RE-CREDENTIALING

Re-credentialing, also known as re-enrollment and revalidation, occurs periodically and requires a provider to repeat the medical credentialing process. Each medical network has its own timeline of when this is done. Providers will receive a letter letting them know that they are up for medical re-credentialing. If they don’t complete this before the deadline given, their medical credentialing is suspended until the process is completed and approved.

In order to avoid termination from medical networks one must keep up their recredentialing.