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 Outdated, incomplete, or missing data usually appears in the following fields: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

How to Submit A Provider Enrollment Application?

How to Submit A Provider Enrollment Application?

Credentialing is a process of evaluation of doctor's practice and qualification. It includes a thorough review of education, residency, training and licenses. All qualifications issued by the board in the field of specialty are also verified. The doctor has to go through this process before joining any hospital's team. Credentials are reviewed on a regular basis and each state has its own standards and regulations.

The main role of credentialing is to ensure quality health care. To submit your application, you should include all information concerning your practice. Gather all your background information and be prepared that it will be checked for reliable sources, such as American Board of Medical Specialties and National Practitioner Data Bank.

If you don't want your application to be denied, include even small details in your application. Add all states where you report an active medical license, all your schools and training programs with start and end dates, include Controlled Substance Registration to confirm that you're authorized to prescribe drugs. Sometimes, you should also prove that you're not banned from treating Medicaid and Medicare patients. Your personal history is also required - different disciplinary actions is a red flag for many hospitals. After receiving your application, the Credentialing Committee will decide whether or not you can participate in patient care in the facility.

Some of your general information is also required. Your name and location, gender and specialty are accepted through a document that states this information is complete and correct. If you're going to provide your services in several specialties, they all should be listed. Patient focus, which shows if you have a patient age specialization, and languages spoken both should be in the application.

Board certifications mean that you have been awarded a certification from the American Board of Medical Specialties. The certificate represents your current experience, skills, and knowledge and ensures you can provide quality care. Many hospitals include board certification into the credentialing process and it's worth valuing your time and effort in obtaining the Certificate.

Credential applications are usually fill able on the computer. Simply fill out all information in the fields, this will provide more easy-readable information - which reduces the amount of questions, mistakes and delays during the credentialing process. Always take a signed copy for yourself before mailing the application to the committee. However, signatures still should be handwritten.

The easiest way to submit your application is via PECOS, or Provider Enrollment, Chain and Ownership System. PECOS helps you with the application, so don't leave blank field and supply all important information. It results in a better-filled and more accurate application and saves a lot of time and money.

You can also submit your application by mailing it to the intermediary that serves your location. To avoid delays, mail your application to the right intermediary. Credentialing isn't a swift process and you really want to plan everything ahead, sometimes even six or nine months before sending the application. Completing the forms takes longer today than in the past due to an increase of required documents, but if you're not going to forego all privileges, you can't do much about it.

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.

Thoroughly Explained Physician Credentialing Process

Thoroughly Explained Physician Credentialing Process

Credentialing process for a hospital is a difficult task, concerning the amount of documents that have to be checked before accepting a provider into the facility. For that reason, you should know how to properly perform a credentialing process.

To begin the process, make the list of pote
ntial applicants. Define those physicians who you think will invest in the facility, but keep the list short. If your center is multi-specialty and the owning entity says the ASC is going to have an open staff, you should go through all specialties and find available physicians. After that, one of the staff members will have a meeting with those physicians and determine whether or not they want to apply for credentials.

The next step is to collect correct contact information. Some physicians want the ASC to go through a nurse or managers, other prefer to be contacted directly. Up-to-date information is a simple thing that can cause lots of troubles if you don't have it. You will have to check in with the chosen physician throughout the credentialing process and send multiple forms, so make sure you have a database of current contact information.

Now it's time for the most time-consuming part - background check. This is the most troublesome task in the credentialing process since one of your staff members should go through all information and then verify that it's accurate and complete. This includes:

•    Verifying employment history
•    Verifying education and training with help of American Medical Association
•    Reviewing time gaps in career and asking to provide explanation if a physician has a gap longer than 6 months
•    Asking the National Practitioner Data Bank about settled and closed claims history
•    Using OIG sanctions database to verify Medicare sanction information
•    Verifying the status of privileges at other health facilities

Once all this information has been checked and verified, you can move to studying references and determining whether or not this physician can treat patients in the facility.

Check if there are any malpractice claims

While checking information through the National Practitioner Bank, you may find information on closed suits, settlements, and other malpractice claims history. If a physician has a malpractice claim, it doesn't mean he shouldn't be credentialed. It's a red flag, but if physicians have closed suits and malpractice claims, it just means you should apply scrutiny to the application.
After your specialist has confirmed the information in the application, it should be sent to the governing body for a final check. By this time, all red flags should be discussed.
Create a list to track the progress of chosen physicians.

You and your credentialing coordinator should keep checking the progress of the application. It's better to do checks weekly and make sure your coordinator knows when forms were sent to the physicians and when they submitted all information to the facility. Besides, your coordinator should also keep track of all references that haven't been responded.

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 Protect Patients Through Privileging

How To Protect Patients Through Privileging

Doctors sometimes have to make life-changing decisions. Patients trust doctors assuming that they have enough knowledge to make these decisions - knowledge gained through proper training and experience. And privileging proves that doctors have the experience and training they claim and can be trusted. It keeps patients safe, and eliminates potential treatment errors. Moreover, if the hospital should have known or knew that their doctor is not qualified enough to treat patients which led to an injured patient, the hospital is liable for giving privileges to that doctor.

Privileging refers to a decision whether or not a physician is allowed to practice within a particular healthcare facility and provide some procedures in a specific clinic. The privileges given to a physician can't be broader that the activities of a certain hospital. Most of the time, privileges copy the set of individual activities a physician is licensed or qualify to perform. Privileges are always site specific since they require consideration of its characteristics like equipment, site size and capacity, number of medical staff, and other resources to ensure the provision of quality health care.

All physicians who provide services which require certification, licensure, or other credentials are required to have those credentials. All privileged physicians performing services have to have appropriate licensures and exclusion status check.
In order to make the right decision about whether or not to approve an application for clinical privileges, physician's credentials are analyzed and aligned with:
•    Site ability to deliver safe patient care of the activity that should be privileged
•    Patient need for the activity that should be privileged
•    Assessment of experience, education, training and maintenance of skills necessary for the safe delivery of privileges
•    Resources available in the facility to provide or support the activities

In a process of getting privileges, a physician will always go through the credentialing process, since there always should be a thorough examination and verification of his skills, education, training, etc. However, if a physician has credentials it doesn't necessarily mean he has privileges.

The purpose of the evaluation of each physician is to determine that a new recruit has all qualifications and competencies to be granted specific privileges, or if it's a current staff member, to determine whether the privileges should be discontinued, continued, or revised. Once the appraisal of individual physicians is done, medical staff will provide recommendation to the Governing body and they will decide whether to grant a particular physician privileges.

Every hospital has to ensure that appropriate hospital departments, patient-care areas and the practitioners are aware of the privileges granted to the practitioner. Hospitals should also inform the physician about the revocation and revision of the privileges. Moreover, there are state and federal law regulations that require hospitals to inform appropriate federal and state authorities, databases, and registries, as well as the National Practitioner Databank about practitioner's privileges being revoked, limited, or constrained in any way.

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.

Things To Consider Before Starting Credentialing Process

Things To Consider Before Starting Credentialing Process

Credentialing is a popular term among providers, especially among physicians who, just ten years ago, could simply perform cash only services. In contrast, nowadays patients are demanding that providers accept their insurances for payment. Hence, those who don't want to lose clients and scare potential patients away should go through the credentialing process.
Getting credentials mean filling out and retrieving multiple applications with insurance companies, then submitting everything to them, and then constantly following up. Even though it may sound simple, many would agree the process is nightmarish as it usually doesn't go smoothly, and many providers have to submit their applications multiple times, spending time contacting insurance companies and fighting delays and rejections. Moreover, many panels can simply say that they don't accept people with your specialty or they are full.
While the credentialing process will never become one of your favorite things to do, there is still something you can do to make the credentialing a bit easier.
Create a list
Research all insurance companies and choose those you want to get credentials from. Each company has its own credentialing process, so be prepared to submit different application forms and go through multiple interviews.
Complete the CAHQ
The Council for Affordable Quality Healthcare, or CAHQ, is usually required to complete the credentialing process. Almost all big insurance companies, like Aetna or BCBS, use CAQH applications. Thus, you should get yourself acquainted with the system.
First of all, you can't simply upload your information on CAQH, you need to be invited there by an insurance company. And if you remember that "chicken or the egg" thing, you can imagine how it feels when you need to submit an application to an insurance company. Once you submit it, you should call them to check if they actually received anything and generated a CAHQ number for you. And then you can go to CAHQ and complete the application that you have already sent to the insurance company, which is waiting for the complete application to arrive.
Never submit CAHQ applications on paper
Even though you can choose to either submit an online application or send it on paper, never choose to send papers. First of all, their application is over 50 pages long. And second of all, when you send your application on paper, CAQH hires a data entry person to transfer your data. And if you think it takes a lot of time...they just never do it. Many physicians have submitted their applications on paper and CAHQ simply lost them. And if you call to CAHQ, they will also ask you to submit the application online.
Devote around 10 hours for each insurance company you want to get credentials from
Don't expect that getting credentials will only take ten minutes of filling out the application. Usually, you need to spend 10 hours of labor for every insurance company. It includes getting and filling out forms and applications, organizing documentations, and checking the process of 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.

 

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.

Important Steps to Physicians Credentialing

As a physician, you already know how important the credentialing process and privileging is. These are two aspects that ensure patient safety and high-quality service, but do you know how to apply for it?

Step one - collecting necessary documents

All physicians work hard to become who they are and credentialing (a complicated process of confirming the qualifications of the practitioner) is the most important part of your ability to perform quality services to your patients. Credentialing simply means the verification process that confirms that you, as a physician, have all qualifications, credentials and background for membership in a healthcare organization (such as a hospital).

The credentialing process includes the confirmation of all professional degrees, licensures, clinical training, training certificates, residence certificates, continuing education credits and many more. All these documents are needed to confirm whether or not you meet the latest standards of practice and regulations set by each institution.

The most common documents that you will need:
• Proof of identification
• Proof of DEA licensure
• Proof of education and training
• Work experience
• Military service
• Board Certifications
• Letters of Reference
• Health Status
• Hospital affiliations
• Criminal check
• Malpractice insurance
• Claims history
• Sanctions disclosures

Unfortunately, there is no centralized credentialing process, so it can get quite complicated and time- and money consuming. You have to create different submissions for every entity, have to keep off the records and make sure that everything is error-free.

Step two -applying for privileges

When you're done with credentialing, it's a perfect time to apply for privileges. It's a process that grants you with an authorization to provide specific services or treatments at a certain healthcare facility. Privileging can be divided into three main categories:
• Admitting privilege that allows you to admit patients to the hospital
• Courtesy privilege that allows you occasionally to admit and treat patients at the hospital
• Surgical privilege that allows you to operate room surgeries

This is an important step in physician credentialing since it ensures the healthcare facility that you have the experience, skills and competencies necessary for the services you're going to provide. Once the privilege is approved, you can conduct certain services in a certain facility. For example, a doctor in private practice may want to apply for privileges to perform surgeries, and can even get privileges from more than one facility. Moreover, hospitals are also obliged to answer regulatory entities like Accreditation of Healthcare Organization or The Joint Commission on Accreditation to ensure all physicians are properly privileged at the facility.

Record-keeping is an important part of successful credentialing process

Just as credentialing, the privileging process is long and complex. You will have to provide a lot of details, prove your education, competency, fellowships, residence, licensure, insurance and many more - and get ready to different interviews with the committee and a board of directors: that is an essential part of any investigation process. Both credentialing and privileging are documented, formal procedures that require adherence to every rule and regulation for granting clinical privileges and admission. This means they are the key parts of delivering patients the highest standard of 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.

©  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.

What is Board Certification?

What is Board Certification?

To practice medicine, physicians have to be licensed by the state in which they're going to work. However, licenses don't guarantee that doctor has qualifications to practice a specific specialty, such as surgery or dermatology. One of the best ways to find out about doctor's qualifications is to know if he/she is Board certified and actively participates in activities to learn about the latest advances in patient care and medicine.

Board Certified physicians voluntarily meet requirements beyond licensing. These physicians show the expertise by obtaining Board Certification through the member Boards that all are part of the American Board of Medical Specialties or AMBS. Before a physician can be Board Certified, he/she has to complete:
•    a training leading to a DO or an MD degree from a medical school
•    four years of education in a university or college
•    five years of experience in a residency program

In the past, boards granted physicians with lifetime certificates, so once they were certified, they got it for life. However, nowadays physicians have time-limited certificates and require frequent recertification. The vast majority of boards require recertification after 5 years with some exceptions. Hospital requirements for certification usually vary, which is based on physician availability. There are areas with an abundance of physicians, thus hospitals require thorough verification of qualification and skill, but in underserved areas, hospitals may not ask for a board certification.

When certification is necessary, physicians should keep track on expiration dates of their certificates. Besides, hospitals' bylaws should clearly define the requirements for board certification and develop a process that will verify the certification. Sometimes, the medical staff requires the certification within a given timeframe or on the appointment, which means that physicians should keep track of their documents and assure they meet the standards. Hospitals usually send reminder letters prior to the expiration date of a current certificate. Whether recommendations are applied, they should be fair and consistent.

Board certification can be verified by collecting information from the board. There are also more convenient ways: board certification for ABMS is verified using the CertiFacts website, and many other certifications can be verified online.

However, hospital's governing body has to make sure that under no circumstances clinical privileges in the facility depend on only upon certification, membership or fellowship in a society or a specialty body. In other words, hospitals have to perform a thorough check of background information and qualifications of physicians even if they have a certification. A hospital can require a board certification when thinking of a DO/MD for membership. However, they should not rely on the fact that a DO/MD is or isn't board certified in making a final decision in membership. In addition to the board certification, hospitals should also verify other criteria such as character, training, judgment, and competence. After a thorough evaluation of all criteria, if these criteria are met except for certification, the hospital can decide to select or not to select a physician to the staff.

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 Is Negligence In Credentialing?

Negligence means a guilty conduct because it falls short of what a person would do to protect another person from a preventable harm or risk. If a healthcare facility could possibly foresee that a physician isn't qualified and the physician injures a patient, the hospital is separately liable for the negligent privileging and credentialing of the physician. Healthcare facilities are legally responsible under multiple theories. Some of them have been held responsible for the failure of the thoroughly screen a physician through the processes of credentialing and privileging, or for negligent credentialing. Negligent credentialing is recognized by at least 28 states. However, there are other theories under which hospitals are held responsible.
Liability theories
There are states where negligent credentialing falls under the corporate negligence doctrine or corporate liability. The main idea of the theory is that when patients enter a hospital they do so with a reasonable assumption that the hospital will try to cure them. Hospitals have the duty to make a lot of efforts to monitor and evaluate the treatment and care administrated and prescribed by the providers practicing in the facility. Hospitals are also responsible for granting privileges only to professional, competent physicians.
The governing body is responsible for making final decisions in credentialing and privileging matters. Although the Board Certification can also be partially responsible, since they verify physician's information regarding his/her experience and training, the ultimate decision-making power belongs to the governing body.
There are two doctrines that make hospitals responsible for hiring unqualified providers. Patients can't choose the practitioners, so it's a healthcare facility who should carefully decide who can be a member of the organization and who can't.
Elements of Negligence
Patients should understand that the fact a hospital didn't credential a physician adequately doesn't mean that the healthcare facility was negligent. For instance, if the hospital can't verify medical licenses for a competent and qualified physician within the requirements of the credentialing standards, this shouldn't be seen as negligence.
In order to establish negligence, one should analyze specific elements. For example, there should be a duty to exercise due care, and duty must be breached. There is also has to be an injury, and the breach of duty should be a reason of the injury. Besides, the patient bringing the charges has to prove that the injury caused him/her compensable damages.
As it was illustrated in a previous example, let's imagine that a physician injured a patient and it was proved that the injury was a result of negligence. If it was proved that the healthcare facility failed to verify the experience, qualification, and competence on initial appointment, and if it would have found that physician's licensure was suspended, only then it can be assumed that proper credentialing wouldn't lead to the injury. In this example, it's pretty easy to conclude that the breach of duty to properly credential that physician could have led to the injury of a patient.
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.