Step-By-Step Credentialing Manual

Credentialing process is a necessary evil every physician has to go through. Postponed or done haphazardly until a month before a physician starts working, it can turn into scheduling nightmares, cash-flow delays, and other unpleasant things. Fortunately, there are several steps to minimize the possible issues with credentialing. The following steps are quite simple, yet proven.

Start well in advance

Though an average credentialing process can be finished within 90 days, give yourself at least 6 months. As payers have supersized, an ability to expedite an application has disappeared. Physicians have to work on a timeline of someone else, usually payers, and each payer has different timelines for processing an application. So, be patient and wait.

Pay a lot of attention

Credentialing managers say that the most common mistake in applications is that they miss information that's crucial for processing. Outdated, incomplete, or missing data usually appears in the following fields:
• malpractice insurance
• attestations
• hospital privileges
• current work status and work history
If you provide a comprehensive list of your training, education, experience, etc., you will probably avoid the vast majority of delays. Getting everything right the first time means you'll get a new physician credentialed within 90 days.

Get yourself acquainted with CAQH

CAQH, or the Coalition for Affordable Quality Healthcare, created a uniform credentialing program 15 years ago. Since then, many payer across the country gave adopted the program. Physicians who update and attest with it find credentialing and re-credentialing processes much easier and faster. CAQH doesn't allow you to follow temptation and leave data entry boxes empty or send an incomplete application. It's important, because applications with missing information are simply rejected. Because credentialing decisions take months, you'll lose a lot of time and have to do a lot quickly. So, with CAQH you'll attach all required documents and provide all information. And never try to simply remember important dates and events - always have your documents with you.

Link a start date of a physician

This can be a bit controversial, since many hospitals are afraid of offending a new physician by asking to submit the requisite credentialing paperwork. However, it's quite comfortable to link a start date to the submission of the paperwork. For example, the date might be at least 3 months away. It's better for both hospitals and physicians, who at least will know a preliminary schedule of the credentialing process.

Know all regulations and laws

Different states have different laws for credentialing, including in-state credentialing (a physician change one practice to another within one state doesn't have to go through all credentialing process again), and reciprocity regulations (if a physician was credentialed in another state, sometimes he/she will have to repeat the process). Usually contacting local medical society or association is enough to get all necessary information, avoid mistakes and use laws to your advantage.

Credentialing can be tedious, especially if you don't provide enough information from the very beginning. Hospitals make strong efforts to gather all data from new physicians, and when done properly, credentialing is a much less painful than it might be otherwise.

Premier Credentialing Solutions, LLC has the best credentialing and licensing solutions for you and your business; We proudly offer Provider Enrollment & Physician Credentialing, Medicare – Provider Enrollment & Revalidation, Medical Licensure Services, and Full-Service Credentialing For Billers / Billing Companies. Call (800) 455-4773 for a free, no-obligation consultation.

©  Premier Credentialing Solutions, LLC.  An Illinois-Registered LLC.  2017.  All Rights Reserved.

Simple Guide For Establishing Credentialing Process

Simple Guide For Establishing Credentialing Process

As a board member, you probably understand the commitment your healthcare facility has to the local community to ensure highest quality care is delivered at your hospital. But do you know the impact of this commitment at every meeting when you grant privileges or give credentials? Physician credentialing is the crucial task you have to undertake to ensure your patients receive safe and quality health care.

Simply put, the main aim of credentialing is to ensure only professional doctors are allowed to be among the medical staff, and that they deliver procedures within their competence and experience. The credentialing process involves establishing realistic requirements and evaluating physician's qualifications for obtaining a certain status. The first step of credentialing includes considering and agreeing on professional experience, training, and other requirements that physicians have to meet in order to get credentials. The second step includes obtaining and verifying information about the skills and qualifications of every physician. In other words, credentialing process is needed to prove that each physician:
• provides honest and complete information
• has all licenses
• has malpractice insurance
• meets the standards established in a particular hospital

In the past, credentialing required applicants to present only several papers, such as their certificate or diploma. Nowadays, however, it's much more complicated and requires verification of primary sources - schools, licensing agencies, residency programs, etc. - to guarantee that physicians' training, education, licensure and other papers are legitimate. Primary source verification is important in both meeting standards of accreditors and avoiding possible legal problems.

One of the key aspects of the credentialing process is granting privileges to an applicant. Granting privileges is a three-step process, which are:
• determination of treatment and diagnostic procedures that a hospital is staffed and equipped to perform
• setting the minimum experience and training needed for a physician to carry out the procedures
• evaluation of whether or not a physician meets the requirements and allowance of performing requested procedures and treatments

Delineation of privileges refers to a process that determines what treatments and procedures can be performed at the hospital. As new technologies are implemented, privileging physicians become more difficult and challenging for hospitals. Delineation of privileges should be flexible, so that hospitals can add new conditions to treat and new procedures, but it also should be consistent, fair, and firm.

To start the credentialing process, the board should specify criteria that will be used to make decisions at each step. The board should also make sure that the process is fair, consistent, functions properly, and thorough.

Then the board should decide which physicians will be allowed to enter the medical staff or remain there, and which conditions they may treat. In the past, boards' role in the credentialing process was insignificant, but today they are directly involved in the process.
Verifying information provided by a physician protects patients and reveals any details that could stay hidden otherwise.

Premier Credentialing Solutions, LLC has the best credentialing and licensing solutions for you and your business; We proudly offer Provider Enrollment & Physician Credentialing, Medicare – Provider Enrollment & Revalidation, Medical Licensure Services, and Full-Service Credentialing For Billers / Billing Companies. Call (800) 455-4773 for a free, no-obligation consultation
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©  Premier Credentialing Solutions, LLC.  An Illinois-Registered LLC.  2017.  All Rights Reserved.

Physician Credentialing Requirements

Physician Credentialing Requirements

The governing body of each healthcare facility is responsible for credentialing process and can delegate some responsibilities to the staff of the hospital for proper implementation. Qualifications to provide treatment and care to patients that are verified include: checking with NPDB, or the National Practitioner Data Bank, confirming current professional licenses, confirming board specialty certifications, checking with HIPDB, or the Healthcare Integrity Protection Data Bank, CSA (Active Controlled Substances Act) database and other databases, confirmation of membership in associations, and confirmation of degrees.

Hospitals may implement different credentialing criteria, but there are still some requirements established in the vast majority of hospitals. It includes competence, character, judgment and experience.

In many states, hospitals also require an active collaborative practice agreement that should be on record before credentialing. This agreement refers to a relationship between a collaborative physician and the NP. It allows NPs to independently care for his patients within given guidelines and according to regulations. When you successfully complete all the paperwork, the hospital will verify that they believe in your qualifications and provide you patient care at the facility. However, re-credentialing is needed every 2 years, so it's vital to maintain all documents and papers.

Privileging refers to a process by which the same hospital that approves your credential application grants permission to provide some aspects of patient care. For example, privileging may include prescribing, admitting and performing some procedures. Sometimes, a physician may be trained, credentialed and licensed to provide patient care by the Nurse Practice Act, but usually your practice is limited by the privileges you got within the facility.

In additional to health care institution credentialing, a physician should also be credentialed by nonprofit and for-profit insurance companies and Medicare and Medicaid programs, which are sponsored by the government. Health insurance organization credentialing will allow you to bill for care provided. The paperwork may vary quite dramatically, but most of the time, you should obtain a National Provider Identifier number, which will recognize you as a unique health provider and also as the one who can maintain licensure and certifications. You can apply for the National Provider Number at the US Department of Health and Human Services. Once you have it, your power and validity as a health provider will increase.

As an applicant, you also have your rights. In particular, you have the rights to be informed of the following:

• Right to correct mistakes, conflicted information and erroneous
• Right to review the information you submitted for credentialing
• Right to get informed of the status of your application, upon request

You should direct all questions and request to the consultant at the hospital you're going to practice in. However, you won't be notified if your application has errors or mistakes and can be simply denied without telling you the reason. Therefore, check your application multiple times to ensure it is error-free and provide comprehensive information about you and your working experience. You're the only one who can correct conflicting information and errors.

Premier Credentialing Solutions, LLC has the best credentialing and licensing solutions for you and your business; We proudly offer Provider Enrollment & Physician Credentialing, Medicare – Provider Enrollment & Revalidation, Medical Licensure Services, and Full-Service Credentialing For Billers / Billing Companies. Call (800) 455-4773 for a free, no-obligation consultation.

©  Premier Credentialing Solutions, LLC.  An Illinois-Registered LLC.  2017.  All Rights Reserved.

The Most Important Provider Enrollment Regulations

The Most Important Provider Enrollment Regulations

On March 2011, new requirements for the HCA (Health Care Authority) were implemented by the Affordable Care Act. These requirements include additional screening requirements for referring providers, disclosures, application fees, and re-credentialing for all providers every five years.

The HCA collects application fee according to the federal rule ($352) from providers before executing the provider agreement. There are some providers, who are exempt from these fees:
• Providers that have paid fees to Medicaid
• Individual providers
• Providers that enrolled under Medicare

Re-enrollment is necessary for all physicians who want to treat patients and have privileges. Re-credentialing includes filling up the application form, attaching all documentation (with updated information), and paying application fee. You'll get a receipt that will mean the beginning of re-credentialing process.

Provider Enrollment on the Portal, or PEP, helps complete the application more thoroughly and carefully and guides you through the entire credentialing process. It has an online application form, where PEP automatically populates identical data field, which shortens the time to finish the applications and refuses errors and mistakes. Besides, it doesn't allow you to submit the application before you fill out all required information. If your information is not consistent, your application will be denied. Before, you had to sign the application yourself, but now with an E-signature feature, you can sign the application online. You can also correct information online, which wasn't possible before. You have 30 days to change information if needed. And one of the most important features is tracking. In the past, providers had to call to the credential manager to find out something about the application. Today, you can receive updates to the e-mail.

There are also new disclosure requirements. Now, HCA is required to collect data about controlling interests of providers, disclosures of ownership, managing employees and helping providers during credentialing process and re-credentialing process. All disclosures should include the name, social security number, and date of birth of the disclosed providers. Everything is collected in the Disclosure Statement and in the HCA's Provider one online application system.

All health care facilities have to complete a financial report presented by an individual accountant of the facility. All documents, notes and schedules as required by the American Institute of Certified Public Accountants should be presented in the report.

If the facility doesn't prepare the report, it should at least provide a statement of revenue, statement of cash flows, changes in earning, and balance sheet. Sometimes audited statements can be in a consolidated format, and may not be audited.

HCA may obtain and use your medical information. It can collect information about you in many different ways. For instance, HCA can get your data when you apply for payment, enroll in UMP, call Customer Service, send claims, or submit appeals or complain. This information can be related to medical care or some general data.

HCA is required to keep this information confidential. It doesn't disclose it to the third parties and can't give it to the providers.

Premier Credentialing Solutions, LLC has the best credentialing and licensing solutions for you and your business; We proudly offer Provider Enrollment & Physician Credentialing, Medicare – Provider Enrollment & Revalidation, Medical Licensure Services, and Full-Service Credentialing For Billers / Billing Companies. Call (800) 455-4773 for a free, no-obligation consultation.

©  Premier Credentialing Solutions, LLC.  An Illinois-Registered LLC.  2017.  All Rights Reserved.

How to Submit Credentialing Documents?

How to Submit Credentialing Documents?

To start the credentialing process you should submit an application. Whether it's a hospital, medical board, locum tenens organization, or an employer, they all have special forms to keep information organized. Your files are checked, reviewed and verified (including NPDB, DEA, OIG and background checks) for accuracy by an assigned coordinator. These coordinators have to collect supporting documents from you, check them, verify the authenticity of information, and prepare files for monthly credentials committee meetings.

A standard Credentialing Committee consists of ten practitioners representing all specialties at a facility. They usually meet once a month to review and discuss files prepared by coordinators. The Committee will either approve or decline your application based on information you provided there. For this reason, it's important to remember that everything you provide in an application will be thoroughly checked. Verifying is the most important part of credentialing.

The requirements for credentialing are constantly changing, and documentations that were not required in the past can play a vital role today or soon will be important. You should scan copies of the supporting documents into image files so they can be quickly transmitted electronically. There are several states (Like Texas), where one standard Credentialing Application is used by all healthcare facilities, and you can usually get it with hospital-specific addendums. Keep all copies of your applications, it will allow you to refer to them and keep records if questions arise. Before filling an application, prepare all important data of your practice history. Don't forget to list all State Licenses you've held, all hospitals you've had privileges, details of malpractice claims (if any), Board Certification dates and disciplinary actions. If the Committee finds out something that wasn't mentioned in your application, it is a red flag and could result in denial of the application. Then, many coordinators report denials to the National Practitioner Data Bank, and it will bring more problems to you.

CV can also be an important part of your credentialing process. There is only one thing to remember about the CV: it should go in chronological progression and have start and end dates. Some providers write only years (like the years in residency, medical school, etc.), but coordinators need your history with dates, as you're required to explain any time gap longer than a month.

Re-application is a long and money-consuming process, so make sure nothing is missing before sending the application. The vast majority of the facilities use the CAQH, or the Council for Affordable Quality Healthcare, to coordinate all information needed for credentialing. If you have never used CAQH, you will have to create your profile and then constantly update your information there. Be sure to carefully choose your specialty in CAQH, because your choice will affect the way claims are paid and proceed and determine whether you can be designated as a primary care specialist.

After everything is sent, you have to be really patient - credentialing process takes a lot of time since your complete history should be verified. Sometimes, credentialing coordinators can estimate the time they need to make a decision. On average, it takes 90 days or longer.

Premier Credentialing Solutions, LLC has the best credentialing and licensing solutions for you and your business; We proudly offer Provider Enrollment & Physician Credentialing, Medicare – Provider Enrollment & Revalidation, Medical Licensure Services, and Full-Service Credentialing For Billers / Billing Companies. Call (800) 455-4773 for a free, no-obligation consultation.

©  Premier Credentialing Solutions, LLC.  An Illinois-Registered LLC.  2017.  All Rights Reserved.

The Process of Physician Credentialing

The Process of Physician Credentialing

Credentialing is a system that establishes contacts between health plans and providers. However, it's riddled with redundancy, and many organizations collect identical information. An average physician spends at least 3 hours every year to submit 18 credentialing forms, and staff spends over 20 hours reviewing them. If you're not going to work in cash-only medical practice, you will have to go through a credentialing process. However, you can handle your part more efficiently. Follow the steps below not to get mired in this process.

Start well in advance

The credential process is not among quick ones. When a new physician is joining the team, you should plan everything months in advance. The same applies if you're a newly recruit associate. The problem can appear when many organizations start asking for the same documents needed for the credentialing process. With that in mind, don't be surprised that it takes weeks to process all paperwork, so if you overlook any request for information, it may cause financial problems, since you can't bill for your services. So, it's important to tie the start date of a new physician to the successful signing of all key documents. Even if you don't want to bother yourself with this and outsource credentialing to somebody else, this person should be able to travel to the physician’s home to get a copy of another document, or escorting a physician to the bank and have all documents notarized, if that's required.

A sustainable process is a key to success

It's understandable that the initial submission of all documents leaves people exhausted, but you still have to make sure everything goes smoothly and you know where all your documents are. Re-credentialing is always somewhere around the corner. There are two main options for handling the workflow, and they depend on the amount of money, time and staff you have (or don't have). You can create a spreadsheet of hospitals, payers and third parties and record there all submissions and deadlines. You can assign an employee to keep all forms signed and updated. Another option is to lease (or purchase) a credentialing software or outsource the entire process to one of the vendors that specialize in this field. Whatever you choose, you should always monitor the process.

Learn about the most important success factors

There are special credential databases, such as CAQH Universal Provider Data source, that won't let you leave any field in the form blank. Remember that with a small detail missing in the form may be rejected. One decision can take several months, so take time to complete every element, and attach all necessary documentation. And don't even try to estimate start and end dates or other data from memory.

Decide what steps you can take in the interim

Some people believe that it's fine to bill under other identification while waiting for the decision of the credentialing process. In fact, this can lead you to serious legal problems if an adverse event happens - the name of the rendering physician won't be the same as the name listens on the medical claims. Besides, some health plans strictly prohibit this protocol of billing under another physician. One of the most common ideas physicians have is to use a -Q6 modifier and bill a physician as a locum tenens. But the best thing you can do here is to learn what is required for credentialing and follow all instructions precisely.

A helpful indicator of a properly running credential process is the record of denials and adjustments that are taken during the billing process. Keep track of the claims denied and the accounts written off, because of incomplete credentialing.

Premier Credentialing Solutions, LLC has the best credentialing and licensing solutions for you and your business; We proudly offer Provider Enrollment & Physician Credentialing, Medicare – Provider Enrollment & Revalidation, Medical Licensure Services, and Full-Service Credentialing For Billers / Billing Companies. Call (800) 455-4773 for a free, no-obligation consultation.

©  Premier Credentialing Solutions, LLC.  An Illinois-Registered LLC.  2017.  All Rights Reserved.

Physicians Credentialing Criteria

Physicians Credentialing Criteria

Credentialing is a necessary evil process. Postponed a bit, it can create scheduling nightmares, cash-flow delays and other troublesome activities. To make the complicated process a little bit easier, there are a number of criteria that any doctor has to verify in order to get credentialed without problems.

Proof of identity
This is a pretty straightforward step, verifying doctor's identity with government-issued papers and quality photo ensures that your identity is correct. That is the very first step that you have to make, and you should submit:
• VISA or employment verification card
• NPI number
• I-9 documentation

Education and training
Don't forget to include all education and training entities that can prove medical school's education and training. They should also include start and end dates. If you have a time gap more than 3 months, you will also have to explain why. These explanations should shed light on important details of your training experience that are not written in self-reported materials. Remember that your explanations provide insights into your past practice that is crucial for credentialing decision. Here you should include:
• Complete list of residency, medical schools, internship and completion dates, as well as any other relevant experience
• explanation of time gaps (if any)
• Fifth Pathway certification
• ECFMG validation

Military service
Just like your education and training recordings, verifying your military experience provides an insight into your past and professional competency. Here you should provide all details about your performance. Explaining time gaps is not as important as before, but don't forget that you need to explain them in a written form. To verify your experience, include:
• The full list of military experience
• DD214 is it's recently discharged
• military branch, if you're currently serving

Professional Licensure
Your obtained, held and rescinds licenses show your professional competency, experience, performance, and demeanor. You should submit the status, dates and validity of all licenses listed in the application. Rescinded licenses once again provide an insight into your history and you should be ready to confirm a written explanation for licenses. Obtained licenses verify your ability to practice in a particular field. Note that you should be licensed in the state where you practice. MSPs directly investigate all license sanctions, revocations, reprimands, suspensions and probations that the licensing entity of NPDB verifies. Simply put, you should attach:
• Copies of all licenses and their issuing date, number, type, status and expiration dates.

DEA Registration, CDS Certifications and State DPS
DEA (Drug Enforcement Agency) confirms your DEA certification. It also states if you're certified to dispense, prescribe and administer controlled substances. Note that the DEA address should match the state where you're going to practice. There are also states that require a specific license to dispense, administer or prescribe controlled substances. If that's the case, you have to obtain either DPS (Department of Public Safety) or CDS (Controlled Dangerous Substance) certifications and abide by state's renewal policies and regulations. Include copies of DEA, DPS and/or CDC certificates and write issuing dates, registration number, status and expiration dates.

Board Certification
The main source for this verification is the certifying Board. Sometimes there are specific state requirements, and this verification has to adhere to them all. For instance, physicians can be required to be members of the ABMS (American Board of Medical Specialties) or the AOA (American Osteopathic Association). Here you should add:
• A complete list of Board certifications plus original dates, expiration dates and recertification dates.

Work History
Your application and the CV will be checked against the primary source. A good practitioner shouldn't have any adverse professional review action taken by work affiliation or by an employer. Adverse actions mean revoking, reducing, suspending or denying to renew membership or privileges in a health care facility. Good standing means that neither clinical privileges nor membership has ever been restricted, reduced, denied or not renewed. You should also provide a written explanation for time gaps longer than a month as well as start and end days. The end dates are needed if you are affiliated with an employer for more than 5 years. Don't forget to include:
• Chronological, full list of facilities in which you have worked (such as hospitals, practice groups, etc.), including start and end dates, date on staff, good standing verification
• explanation of time gaps

Criminal Background Disclosure
Background disclosure should include a National Criminal Search and a Country Criminal Search. It's needed to check your criminal activity within the last seven years. MSPs quires the Country and National Criminal Searches for all countries in which you have worked or resided. Criminal Searches use different databases to collect all important information such as terrorist activity and sex-offender data. If you have felony convictions, criminal or rehabilitation history, it will require a more extensive check. Criminal background check happens during the initial credentialing and every four years after that.

Premier Credentialing Solutions, LLC has the best credentialing and licensing solutions for you and your business; We proudly offer Provider Enrollment & Physician Credentialing, Medicare – Provider Enrollment & Revalidation, Medical Licensure Services, and Full-Service Credentialing For Billers / Billing Companies. Call (800) 455-4773 for a free, no-obligation consultation.

©  Premier Credentialing Solutions, LLC.  An Illinois-Registered LLC.  2017.  All Rights Reserved.