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 Outdated, incomplete, or missing data usually appears in the following fields: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.

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.

How To Perform The Criminal Background Check During The Credentialing Process

How To Perform The Criminal Background Check During The Credentialing Process

Credentialing means a process of collecting, verifying and evaluating the qualifications and skills of physicians to provide quality care services for a healthcare facility. There are three main components of the process: education and relevant training, current licensure, and current competence, which allows to perform certain procedures and treatments.
Credentialing committees have to deal with credentialing applications daily, but how can a criminal background check complement this process.

Background check and credentialing

Medical staff service is a governing body of a healthcare facility and is responsible for working with independent physicians who serve the hospital. Many physicians appointed to provide services are not actually employed by the hospital, and that's why human resource department doesn't perform the background check and verification of provided information. But the credentialing committee does. The background check is an analysis of criminal records, education verifications, professional licensures verification, training verification, and that's just a few components out of many. For the credentialing committee, the process of granting credentials also includes verification of clean background information. They check peer recommendations, malpractice claims and insurance statuses. The goal is to protect patients from unqualified physicians.

Background check is a risk mitigation tool

While medical service doesn't perform the same employment activities as the HR department, they perform a thorough background check on all physicians applying for credentials or privileges, since it's one of the best ways to mitigate risks for the hospital and protect its patients from preventable serious mistakes.

Checking a criminal history (if any) on a physician performing procedures on the patients can save your reputation. While in some states medical board can perform the criminal background check on physicians applying for licensure, not all of them are allowed to do it. However, even if they have the authorization to perform background checks, they may have limited access to different databases. Moreover, medical board may not perform a thorough check and fail to define troubled physicians. So, without a background check, you may overlook some serious records of a criminal history.

One background check may not be enough

Even if the medical board performs a background check on physicians applying for privileges at the hospital, they can't prove physicians haven't committed any crimes since then. Even if there is a medical staff office at the hospital and they perform their own check, it shouldn't be done only once. To reduce risks, the trend in healthcare facilities for constantly performing background checks is emerging. For example, many hospitals re-check the background criminal history every year, to minimize levels of risk for the healthcare facility. Some hospitals perform a re-check of background information every two years, and a lot can happen during this time. As many experts explain, a criminal background check is a snapshot in time - it's always possible to find something new in future, something that you didn't find on the first background check performed during the credentialing process.

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.

What Does Credentialing Mean For A Patient?

What Does Credentialing Mean For A Patient?

Nowadays, it's really important to understand the meaning of credentialing and what means when a physician is credentialed or have privileges to treat you. If the physician doesn't have one or both, it can mean treatment options for you are strictly limited.

Unsurprisingly, every patient searches for a competent and appropriately trained physician. Unfortunately, fraud is something to be aware of. For example, in California, two unqualified individuals posed as doctors which led to patient harm.

That's why patients should know about credentialing - a process, that verifies qualification, training, and practice history of a physician, which protects patients from being duped. It also protects you from those providers who had sanctions levied against their license. To get credentials, physicians should fill out an application and submit it, but prior to that he or she should make sure no little detail is missing. Work history and specialty boards are one of many things that should be carefully checked before submission.

Copies of all documents - residency certificates, medical degrees, etc, - should accompany the application. Physicians should also provide professional references that can prove the competency. A declaration, which confirms that the physician has never been fired from a job for competency issues, is also required. All in all, there is a long list of documents that should be provided in order to start the credentialing process. Among them, there is a confirmation of not being an addict, convinced felon or hasn't been disciplined for illegal or questionable activity. Then every hospital has a committee that reviews the application and then grants or declines privileges and credentials to provide services in the facility.

Before the committee grants credentials or privileges, all information is thoroughly checked and verified. This makes sense, because too many people make mistakes, embellish or even lie on their applications. For example, the biggest fraud in history is lying about graduation from one of the best Universities and having a Ph.D. The job of credentialing committee is to check up on all the details. In the example above, that person managed to hoodwink all verifies and was picked up much later by accident.

Physicians should also go through the process of -re-credentialing at least every three years, although they can do it more frequently. Re-credentialing is necessary to provide all changed information for verification. This process is almost identical with the credentialing process; however, practitioner's work history, education, and training aren't verified. Re-credentialing is necessary to check physician complaints and sanctions, so that they can react on safety and quality issues that arise.

Simply put, credentials are a proof of skills and competence. Verification of all licenses, education, training, insurance, identification and all history related to professional activity doesn't leave a chance of fraud. It may sound quite simple, but this process is really complicated and time-consuming and physicians have to go through all this to get verification. Those physicians, who understand that this process is necessary, care both about the facility and patients. And patient safety should always be the first priority.

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 Go Quickly Through The Application Process Of Credentialing

Provider credentialing is not just filling multiple forms; it's an ongoing, complex process, which is extremely important for every healthcare facility. Without proper credentialing, physician reimbursement for services can be denied, or, at least, delayed. Given its deadlines, many steps and uncertainties, physician credentialing is critical for hospital's practice.

Put simply, credentialing means verification of your expertise, experience, willingness to provide quality care, and interest. Many professionals describe credentialing as obtaining hospital privileges, as well as enrolling in health plans as a participating physician. Even after submitting multiple forms and documents to different third parties to verify your information don't think everything is done. Even though health plans and hospitals don' require a re-hashing of the process, many oblige physicians to submit their updates annually. It means, credentialing process never stops, it consumes hours each year, and especially if you don't follow it properly.

Although a lot of people now use CAQH and different credentialing software to reduce paperwork, many hospitals still prefer managing everything manually or using electronic databases that can't be connected to other systems. The process is usually not flawless and a lot of time is spent researching and maintaining credentialing files for physicians.

Not only completing all application takes a lot of time, but hospitals spend even more time to perform the credentialing process. Unless you're going to work in a cash-only practice and forget about hospital privileges, you should try to find ways to make the credentialing process faster and easier.

Whatever you do, don't expect that everything will go smoothly. You should start planning months ahead, especially when new physician is joining your staff. Unfortunately, many organizations require the same documents needed for credentialing process at the same time. With that in mind, you should allow enough time for every organization to process their own paperwork. A physician who ignores your request for additional credentialing information can become a financial problem - he/she simply can't bill for services. Consider trying an initial paycheck or a new start date to successfully gather, submit and sign all documents. Even if you prefer outsourcing credentialing to third parties, you still need a person to pursue the process - somebody who can go to physician's home to get a copy of the diploma or deliver all documents to the bank to get them notarized.

While initial submission of all applications can be quite time-consuming, it's important to make sure that somebody maintains all forms because re-credentialing is coming soon. Many hospitals can't support a lot of credentialing managers, so there are not that many options for them to handle the workflow. The easiest and the cheapest option is to create a spreadsheet of payers, third parties and hospitals that should be constantly updated and have all deadlines and requirements. Or hospitals may assign one of their employees to monitor the credentialing process and take actions to get data gathered and forms signed. Regardless your decision, always monitor the effectiveness of the process to ensure you're getting your money worth.

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.

What is Credentials Verification Organization?

What is Credentials Verification Organization?

Credentials verification organizations, or CVOs, gather and verify necessary information about practitioner's education, background, experience, training, skills, and competence, just like a traditional medical office in a hospital would. Nowadays, there are over 100 CVOs in the US, and the vast majority of them are certified or accredited by the National Committee for Quality Assurance, or NCQA, or Utilization Review Accreditation Commission, or URAC.

Some of the first CVOs were just agreements between the groups of hospitals in a local community to jointly share available information about applicants. One medical staff office was required to confirm training, education, and residency, gathering references, verify certificates and licenses, etc., and then send information for use in other hospitals. Later on, with the advent of the databank, it was decided to make multiple inquiries for the same doctor acting as an agent for many hospitals. As time passed by, both non-profit and for-profit organization also entered the business.

Don't confuse CVO with other organizations that just gather, store, and disseminate professional information given by practitioners. There are common applications that can't be used for the process of verifying all information and those organizations can't collect additional information needed for the credentialing process and executive committees. Simply put, CVOs acts as an agent of providers to verify, collect, store and disseminate information about the professional history of the practitioner. Licensing and accrediting organizations don't require CVOs to be certified or licensed, just like hospitals don't require to be accredited. CVO seeks out accreditation to assist in marketing activities and distinct one practitioner from another.

A hospital may assign any organization as an agent for gathering and verifying practitioner's information, provided that the hospital has decided that this information can be collected and verified so that it meets all requirements of a hospital and various accreditation agencies and licensing organizations.

When an organization is certified by URAC or accredited by NCQA, the hospital may accept this accreditation without any evaluations or investigations. If the organization isn't certified or accredited, the hospital has to conduct an evaluation and investigation of the structure, outcome, and documents of the organization. It can be done either in an internal memorandum or in contact.
URAC and NCQA are the only organizations that are allowed to certify or accredit CVOs. None of the organizations that accredit hospitals (such as DNV, TCJ, and HFAP) can approve or accredit CVOs.

For those hospitals who really want to perform their due diligence, there are some questions that will help start the process. For instance, does the organization have a physical location? Does it maintain liability insurance? Or Does it have articles of incorporation? If you're satisfied with the answers, you won't have licensure and accreditation problems that usually appear from complete reliance on data provided by the CVO. If you have established a CVO as a part of the hospital system, it will be considered as a parent organization and its findings can be relieved upon just like it happens with a traditional medical office.

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 Make Sure Of The Doctor Experience And Qualifications

How To Make Sure Of The Doctor Experience And Qualifications

Credentialing process usually mean that a hospital aims to optimize the utility of their crucial recourses - providers - and ensure highest quality patient care possible. The concept is quite old and slowly getting easier, thus more and more hospitals try to perform a thorough credentialing process and creating new quality standards.
Professionals determine credentialing as the process of collecting, verifying and evaluating qualifications and skills of healthcare providers who want to provide patient care services in a certain healthcare facility. Each hospital has its own set of standards and requirements that their providers have to meet. Credentials mean evidence of training, education, licensure, skills, experience and other qualifications.
There is also a process called privileging that accompanies credentialing. Privileging means a process by which healthcare organizations allow practitioners to perform a certain set of services related to their specialty, based on thorough evaluation of their credentials. Credentialing and privileging ensure medical quality; they help assess initial qualification and prove competence.
Verifying quality care
The importance of credentialing can't be underestimated and hospitals have to credential their providers to ensure quality care. It's vital to maintain the high standards of medical care, thus regular verification of qualification and re-credentialing ensure patient safety, provision of quality health services and reduction of possible medical errors.
Hospitals are expected to provide quality care through accurate diagnoses and proper treatment of their patients who come to get the services. Medical providers are the ones who deliver these services and their level of competence and knowledge determines if the patient receives appropriate care.
The credentialing process also ensures that hospitals act according to current laws, state and federal requirements and standards of other certifying organizations that relate to operation of hospitals with regard to the recruitment of its practitioners. Credentialing helps prevent the hiring of a candidate with fraudulent training and degrees to the hospital. After getting credentials, privileging process ensures that practitioners are allowed to perform a certain set of procedures under supervision at the hospital.
Basics of the credentialing process
Professionals believe it's better if every hospital develops its own standards and documents of this process, thus it's impossible to find a guide with all steps that will describe norms and procedures of the process. However, there are many similarities in processes of different hospitals; they mainly differ by specific characteristics of each facility, such as recourses, patients served, etc.
The only way to determine the qualifications of medical providers is to get information about their education, training, and licensure, and to review their data in details. The methods that hospitals use to accomplish this difficult task should become routine as the medical staff becomes familiar with them.  The hospital has to be sure that its patients are treated properly and that it hires only qualified practitioner, who would perform certain services to the patients.
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.

What Does The Affordable Care Act Mean For Americans?

The Affordable Care Act, or Obamacare, will reduce prices for health coverage making it accessible for millions of Americans. Almost 60 million Americans live without insurance, and the law addresses issues concerning inequalities in affordability of health care services, increase access to affordable, quality health coverage, invest in wellness, and give people control over their health care.
According to researchers, there are higher rates of disability, mortality and chronic disease in rural areas. For that reason, the Affordable Health Care Act will transform the insurance industry to improve the health of rural Americans.

Health Insurance Marketplace and rural coverage
At the beginning of 2014, almost 8 million rural Americans under age 65 got new opportunities to get affordable health care through the Affordable Care Act. Just think of the numbers:
• Almost 20% of uninsured Americans live in rural areas
• The vast majority of rural Americans lack proper health care compared to urban Americans
• Rural Americans usually have lower income level, thus subsidized insurance coverage through Marketplaces is necessary
• the Health Insurance Marketplaces should increase competition in rural areas - especially in those states where one insurance company dominates more than a half of the insurance market
• Residents of those states that are expanding Medicaid will get affordable coverage
The Marketplace will lower costs due to increased competition. It will influence rural areas the most, since at least one out of every five residents there faces medical debts and families have to cover almost 50% of the health care payments out-of-pocket.

The Affordable Care Act for Rural Americans
Uninsured Americans from rural areas can use the Marketplace to compare different insurances based on benefits, quality, price, and other factors knowing all premiums and cost-sharing amounts, which should help them pick the perfect health insurance plan that will fit their needs. Each insurance plan should at least cover all essential health benefits, such as emergency and inpatient services, prescription of drugs, behavioral health treatment, and pediatric care.
New coverage options with insurance benefits are already there for rural Americans:
• More than 30 million Americans now can expand preventive services without cost sharing. Among these services, there are blood pressure screenings, well-child visits, mammograms and pap tests for women and flu shots for adults and children
• Over 11 million disabled rural Americas who get coverage from Medicare now also can access different preventive services without cost sharing, such as colorectal cancer and diabetes screening, prevention plans, bone mass measurements, and many others
• More than 600,000 rural Americans below 26 now are covered under individually purchased plans or their parent's employer-sponsored plan
• Private insurance policies can't have lifetime limits anymore, and annual limits should be more than $2,000,000.
• Americans under age 19 cannot be denied coverage due to a pre-existing condition
Insurances won't have to be cheap, but they certainly will be less expensive and you don't have to pay unexpected costs out of the pocket as if you did without insurance. There are also tax breaks for families with low incomes, which help pay for their insurance.

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.  2016.  All Rights Reserved.

The Difference between Privileging and Credentialing

The Difference between Privileging and Credentialing

You can often hear that hospitals use the term credentialing while making decisions regarding its practitioners and granting privileges. These two terms are related, but still quite different.

Basically, the term credentialing means the verification of physician's education, experience and training. Hospitals may also extent the term to include evaluation of collected data and making a decision about a physician. In this case, hospitals say that a physician has been credentialed as a staff member.

There are many types of credentials, but three main ones are used by all hospitals - licensure and re-licensure, college or university degrees, postgraduate work, certificates and awards. Some hospitals also require a proof that the physician has completed either a defined number of certain patient care treatments under supervision of a professional or an accredited training program for the activity he/she wants to perform. Hospitals perform a thorough check of all physician background information, and can search for signatures of supervising professional, documentation of special training and education, log book's recordings, etc. To give credentials, hospitals also check fellowship or residency training, board certification, and competency-based education.

Privileging is something different. The term means that a physician has been allowed to perform certain activities in a healthcare facility. It's important to understand the differences between privileges and membership. Membership means that a physician is a member of medical staff and can attend meetings, vote and receive benefits of the membership. There are also requirements that come with membership, such as attending patients in the department, paying dues, etc. Privileges are required in order to provide treatment to patients.

The processes of privileging and credentialing are defined at hospital's bylaws and in policies and procedures. Getting credentials and privileges is a necessary part of providing services to patients. Most of the time, the first step in the privileging process is to get an application for privileges. It's quite common for hospitals to create application packets that include the list of data required to get privileges. The physician submits a list of the requested privileges and proves that his/her credentials are real. The main task of credentialing is to verify the physician's qualification. Sometimes hospitals can grant temporary approval of privileges, while the credentials are being verified.

Credentialing process is usually held by a credentialing committee, which can also grant privileges. The credentialing committee consists of representatives of physicians who have privileges in that healthcare facility, and they make recommendations about the applicant to the governing body (for example, the medical staff executive committee). Different hospitals may have different committees. They can be composed of medical staff with administrative representation, or be more of an inter-professional group.

In some hospitals, staff is required to take care of the administrative process of credentialing and privileging processes, and then they should send information to the administrative body for a final decision. Besides, demand for credentialing has created many private credentialing services. These services usually help process application packages, verify credentials and send information to the organization.

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.

How To Effectively Manage Credentialing Process

How To Effectively Manage Credentialing Process

Ensuring that your providers are credentialed is the crucial part of saving the practice. From education background to clinical research to board certifications, a lot of data must be collected and verified for each physician to confirm that they meet necessary qualifications of a healthcare specialist.

Have a look at the new recruit's data

When you're recruiting, try to align the credentialing process and the recruitment. Most employment contracts are built on the fact that the employer should get credentialed, thus if the physician doesn't get credentialed, that's a disaster for all parties. The leader of the hospital is 6 months behind in hiring a new physician and reputation is ruined for bringing a provider who can't meet the standards. The new physician may have relocated the job and waiting for a paycheck that will never come. Besides, he can even sue the group for failing to provide the promised job. And when providers don't get credentials, private insurance companies, Medicaid or Medicare can refuse to pay for certain procedures, reducing your incomes. Therefore, its leader's responsibility to check all physician's references, background information and demand explanation for any questionable data before offering the job.

By reviewing all gaps in employment, malpractice issues and references you can make sure the physician won't have problems with the credentialing process. Sometimes, credentialing committees ask for additional information and explanations. It can be asking simple questions about any given reference, or reviewing malpractice suits. The committee can also send documents to a third party for an independent check.

Keep all information in one place

Get credentialing software to keep all information secured inone place and allow staff to view the credentialing process and tasks that need to be completed. With provider's data and supporting forms connected in a single accessible record, your staff can rapidly provide and update their information. Besides, many different credentialing programs notify you about licenses that are near expiration, so you can proactively manage re-credentialing process as well.

Hospital credentialing is not the easiest process to complete, but at least it is more serious and organized now than it was before. However, new physicians still have to provide all applications and forms during the process. And hospitals must protect their patients. It's their responsibility (even though they have to rely on physician references), and hospitals can get sued over poor credentialing or end up in a court when a physician has its privileges removed.

What are the chairman's responsibilities during credentialing process?

It's chairman responsibility to investigate all the skeletons. If you're recruiting a physician who has some questions on the records, devote some time and get all the details explained, so that you won't have to fight problems during the credentialing process. If there is something that looks like regret, now it's time to search for another recruit. But if you still believe that the physician provides quality care, spend some time discussing all the problems with the credential committee to see what they need in order to finish the credentialing process.

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.

How To Find A New Provider?

How To Find A New Provider?

If you want to change a doctor, you should go through a seemingly simple process - leave one doctor, find and see another one. When you think you have enough reasons for changing providers, you'll want to be sure you get the perfect one. If you don't do everything the right way, you may have a lot of headaches when it comes to finding a person who can meet your needs.

Things to do before you leave your current provider

If finding a new doctor is not mandatory and just your choice, perform a little search to be sure there are candidates that suit your needs. Some doctors don't take Medicaid patients, others don't treat new patients. Skillful specialists are booked months in advance, and you need to spend some time finding a new doctor before leaving another behind. Don't forget to schedule a visit with your current doctor. Take notes and ask a report on recurring and current conditions. If possible, take a new provider with you. You can also explain reasons for leaving - even in big cities the community of specialists is small and you don't want any rumors about your hospital.

Your leaving doctor should give you all copies of medical records that relate to chronic or current problems of the patients, which can be useful for a new doctor. Besides, it's required by HIPAA government policies that you can access this information. However, there are different laws in each state about health records, and how they should be carried out. Besides, if your doctor prefers EMR (electronic record keeping), then you can ask your new doctor to use the same system and alter the process. Once you've had a conversation with a leaving doctor and collected all copies, you can start to get a new one.

Visiting the new provider

Assuming that you have a replacement for the leaving doctor, there are necessary steps to develop the right relationships with the provider. Make an appointment with the new doctor and talk generally - it's better than talk while having sick patients or discussing problems at work.
You already have all the copies, but it's a good practice to have a second set of the records so that you have one set and your new doctor has the second set. If possible, send the copies as soon as possible and don't give them during your first meeting - it's better to have more time to talk rather than to read documents.

Think about the questions you want to ask your new doctor and write them down. It's up to you if you want to tell the new provider why you left the other one behind. If you decide to share this information, remember that it's a foundation for the new relationships. Discuss everything politely and respectively. You need a professional relationship, and that's going to be the start.
Once you work with your new doctor, remember that you need to invest a lot in the relationships. Your new provider will help your patients, so it's your responsibility to provide them with quality health care.

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.

How To Choose The Best Physician Credentialing Software

How To Choose The Best Physician Credentialing Software

The current shift from fee for service to fee for quality has attracted bigger audience to health management. Those healthcare organizations who want to ensure efficient clinical delivery base should have started consolidating clinical providers at higher rates. Hence, new credentialing software is needed to handle all the complexities of multi-provider, disturbed, quality driven reimbursement model. The proper credentialing software has to offer are venue-centric solution and help healthcare organizations meet their financial and operational needs that healthcare management requires.

24/7 accessibility

Before buying credentialing software, go through all its features and evaluate if it can perform everything you need. At the very least, it should have 24/7 accessibility, so you can get your credentialing data at any time. All information should be stored in the cloud where healthcare managers can identify where they are in the credentialing process and ensure you aren't losing revenue on delayed applications. Moreover, being in a cloud means a reduction in capital expenditures since there is no need for another software, servers and hardware to subsidize the credentialing system.

Financial performance and payer operational metrics

Another important feature is institutional, financial performance and payer operational metrics. It means that leaders and managers of a healthcare institution can identify how the facility is performing from the financial and operational perspective. It also allows evaluating provider's individual performance. As any leader knows, understanding performance of providers is the first step of improving financial performance.

Generated work list capabilities

As a leader of a healthcare facility, you should require system generated, flexible work lists that your staff can use to meet their credentialing demands. No more calendars and post-in notes that remind you about stages of the credentialing process. The efficient credentialing software will help you go through each step quickly and without mistakes. Besides, healthcare leaders can easily evaluate the work of their providers and establish different metrics.

Assurance tools and mechanisms

The ability to track and monitor credentialing processes of the providers is a necessary feature of credentialing software. Quality monitoring and staff training should be ongoing, don't just leave it be.

Productivity tracking tools

Credentialing software should be able to track statistics and productivity metrics. What is your staff doing on a weekly, daily, or hourly basis? Are these just miss-guided, pointless efforts? The ability to track productivity metrics makes providers more efficient and ensures you're not losing revenue.

Combined credentialing concepts and revenue cycle

Understanding financial impact of the credentialing process helps meet the demands of health management initiatives. And when you know the impact, you'll see if you're losing revenue because providers aren't credentialed properly.

Revenue management

Credentialing software should give you suggestions that help ensure profits and sustainable growth of the facility. Keep all the processes streamlined and build a close network to keep your facility going.
Investing time and money in advanced credentialing software is always a good idea. Otherwise, you risk facing credentialing denials and lost revenue.

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.

What's The Difference Between Credentialing And Contracting?

If you're a health department that wants to start a billing program or is going to expand, you have probably heard the terms Contracting and Credentialing before. These are very important steps that you have to complete, or you can't bill private insurance companies for services your hospital provides, losing a huge part of revenue. But what these two terms mean and where should you start?

The main points of credentialing

Local health facilities can start billing insurance companies only after they've got credentials. Credentialing is a process that private insurance companies use to verify, obtain, access, and validate a healthcare facility in order to ensure it's a reliable place and for liability purposes.

The start of the credentialing process, create a file folder for an insurance company. Different companies require different documents and forms, and folders will save your time and help you to simplify and organize the process for every payer. To choose the best insurance companies among many others, try to create a survey and ask your clients about their companies to see which are used the most. The most common ones should be among the first ones.

After you have created the list of companies to get credentials from, you'll need to get acquainted with the requirements for every company. Each insurance company has a web page where they state all necessary forms and requirements. From there you'll get all relevant information, provide all documents and fill out all forms. Submit everything you get, and you should get credentials within 180 days. And when you're credentialing, it's time to think about contracting with companies.

The main points of contracting

Contracting refers to the process of creating agreements with private insurance companies to become one network with them. It includes establishing services covered, rates, payments, and other information with each company. Every company requires a separate contract.

If you find credentialing process hard, then you should know that contracting is much harder. You will have to negotiate a lot of things with all insurance companies and your success depends on talking to the right person within each organization. You can try to speak to directors and administrators who have some useful contacts to make the process easier.

In today's world of revenue cycles and health insurance, it's important to remember that improper credentialing may lead to serious consequences, such as denied or delayed reimbursement for services provided. Even worse, it may lead to consequences in terms of compliance violations, which means criminal charges and monetary damages.

Some payers take a long time to get to your case and you may face multiple delays. They arise from the non-standard language some organizations use. Sometimes you will have to work with payers to revise the language. It will require even more time.

Healthcare payers often don't know much when it comes to understanding what billing services what local organizations provide. So, it's always a good idea to be persistent and remind them from time to time that it's very beneficial to contract with your facility.

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.

How to Avoid the Most Common Credentialing Mistakes?

Credentialing process is a necessary part of a successful physician practice with steady cash flow and patient referrals. Avoiding these common credentialing mistakes will make the process move more quickly and efficiently.
Providing incomplete information
The most common mistake many physicians make is a lack of attention to small details. Errors and mistakes in application lead to delays and even denials. Different healthcare facilities may have different application forms, but typically you need to submit your phone, tax, address, services provided, contact information, employment history, copies of licensure, patient profile and legal troubles regarding your practice if you have any.
What can you do? Thoroughly check your application a couple of times to certify its accuracy before sending it to the credential committee. Getting everything right the first time means you get credentialed much faster.
Not following up
Be prepared that your plans can be backlogged with the credentialing process. Do everything you can to confirm that your application was successfully received and know where it is. If something sounds like complete nonsense to you, ask questions and wait for the response. Many physicians have no idea of where in the process their application is and what each stage means. Make sure you have no more questions before accepting the answer.
Follow up from time to time and don't forget to make notes. E-mail your contacts, phone if you need to and check all web directories. Never call to explain delays or notify about updates. The only way for you to find out something about the application is to follow it up regularly. Make it a routine and keep up until your application is approved. Remember that you're the one who is concerned about the process.
Don't allow CAQH lapse
If you already have a CAQH profile, you know that it should be updated regularly. Always keep up-to-date all contact information and re-attest your data. You should act proactively when you receive an updated insurance, license, DEA or any other document and get everything loaded to your profile with new expiration dates. It will help avoid delays in the process of re-credentialing.
Not knowing the standards and guidelines
Application forms in Medicaid, Medicare and other government health programs are completely different. They all have standard forms that must be appropriately filled out and sent to the intermediary. These applications, then reviewed against very strict standards. Many physicians make the same mistakes in the following:
• Using outdated/irrelevant applications
• Using incorrect forms
• Submitting incomplete applications
• Submitting to the wrong intermediary
• Not submitting required forms
• Not using verifiable practice location as a practice address
• Not signing the application in all fields
Not giving enough time
Many physicians start too late and this is a reason for their failure. You really need to give yourself at least 3 months. The responsiveness of your application will be determined by the motivation to add a new doctor to a team and the workload.
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.

What's Important To Know About The Credentialing Process?

Physician's credentials - certificates, diplomas and licenses on the wall - tell patients about their professional skills and qualification to treat them. In the US, professional organizations, state and local governments establish the credentials that physicians need to provide their services.


Practitioners are credentialed and then privileged - healthcare facilities verify education, license, and qualification - upon hire and then every two years. Physicians can get privileges after thorough evaluation and verifications of the training and education they have presented. Privileges allow physicians to give the care treatment and services by the facility to the patients.


The most important thing to know about the credentialing process is that there is no national, standardized system for credentialing physicians. Each state and local government is responsible for deciding what physicians have to provide to get credentialed. Those credentials may vary quite a lot from state to state and among different disciplines.


Patients should note that certificates, licenses, and regulations can't guarantee effective, safe treatment from any physician - complementary or conventional. Tell your physician the complementary health approaches you prefer. Tell them everything you do to take care of yourself. This will ensure safe and coordinated care.


Apart from credentialing, you could also hear about certifying and licensing. Credentialing is the broader term that refers to doctor's license, certification, or education. Professional organizations give certifications, government agencies grant licenses. Note that being certified or licensed doesn't mean being qualified.


The vast majority of states use the approaches below to credential doctors:
•    Title licensure: requires doctors to obtain credentials prior to using a title
•    Mandatory licensure: requires doctors to have licenses to treat patients
•    Registration: requires doctors to provide information about professional education, experience, and training


To get a license, you should carefully read requirements of each state. Among everything else, they may ask you to:
•    meet certification requirements
•    graduate from a certain program
•    pass exams
•    Complete a training program


The services you're allowed to provide also vary from state to state. For example, some states don't allow acupuncturists to recommend diets to patients, while others recommend doing it.


Some professional organizations offer additional certification examinations. Certifications qualify doctors for local or state licensure. For instance, in some states, doctors who don't have an M.D., have to be certified by the National Certification Commission if they want to be licensed.


Educational programs in the US train physicians and prepare them for future certification. The Department of Education authorizes specific organizations to accredit training programs for doctors.


The credentialing processing time varies from one organization to another. Sometimes plans take 6 months to complete the process and then 50 days for contracting, while others need 3 months to finish everything. When you submit documents for contracts, enrollment or follow-up on your application, it's important to keep track of the process by utilizing fax logs, certified mail, and documenting all conversations. Once the credentialing process is complete, you will be offered a contract and will be able to treat patients in the facility.


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.

How Long Does It Take To Complete Physician Credentialing?

It's quite common that a new physician joins your healthcare facility either from another practice or out of residency. It's the time when you have to deal with many managed-care organizations or MCOs, so your new physician needs to be credentialed.

This process requires a lot of time and effort. First, you have to collect all documents from the provider - from valid state license to hospital privileges to confirmation of malpractice insurance. Then you have to wait at least 30 days (but it usually takes longer) for the MCOs to check and verify documentation before the new physician can be added to the panels. During this time, the physician is not allowed to treat your care patients. At least, the physician will not be reimbursed for treating, which dramatically limits the ability of the physician to create revenue for your facility. At this point, many start asking why this process takes so long. Is there any way to reduce delays? Below you can find some tips to help you and your facility.


Why is this process so long?
There are many reasons for delays, but the main ones are MCO's desire to match the NCQA (National Committee for Quality Assurance) standards and inefficient planning on the part of practices and physicians.
One of the NCQA standards that are called the Initial Primary Source Verification stipulates that the MCO should verify several documents, like records of professional liability settlements, prior to assigning credentials. When the MCO really wants to meet this standard, they make withhold credentials from a new physician until the very last detail is verified.

Poor planning is also a popular reason for delays. Quite often, new physicians don't start credentialing process until they arrive at practice, even though they've started filling the applications months earlier. And there can be a huge delay since collecting references can take months and then weeks until they arrive. Until all information arrives at the MCO, an application cannot be considered complete - and while it's not complete, the credentialing process is stalled.

For that reason, many healthcare facilities require submitting application at least 90 days before the physician's start date. The processing time can take less than 90 days, but it's a benchmark since it allows extra time when some documents can't be verified in timely manner or discrepancies is required.

You should just keep in mind that credentialing process will take as long as needed to collect all information, receive board recommendation and verify all sources. It's hard to estimate the minimum or maximum frame for the credentialing or privileging process, which both may take longer than three months. Medical staff bylaws, which define privileging and credentialing processes, specify that applications must be acted upon a certain period of time. Some credentialing applications may be finished faster than others, and it always takes longer if the primary source can't be verified, if a physician omitted information or made mistakes on the application, or if there are red flags that require careful investigation.

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.