Why Do Providers Need to Be Credentialed?

In order to make sure that healthcare practitioners are qualified and compliant, provider credentialing is essential. When a provider applies for an organization, the organization checks its credentials. You can select qualified medical practitioners by understanding the importance of provider credentialing to ensure that your patients get the best treatment. So, credentialing makes it easier to find high-performing medical professionals. 

What Does Provider Credentialing Include? 

A regulated procedure for determining a provider’s qualifications is called provider credentialing. It is essential to medical billing services, including doctors, dentists, and other allied healthcare professionals. It includes demonstrating the necessary education, training, and licenses to offer patient treatment to pass this crucial safety check. Prior to adding a provider as an in-network provider, hospitals and health plans check the information the provider has given them.

 

Credentialing entails assessing various elements, such as training, place of residence, work history, credentials, and so on. The performance of the practitioners may get surprisingly high if they possess better credentials. 

Provider Credentialing: Requirement of Payers 

This credentialing procedure is also mandated by the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission) and the Centers for Medicare and Medicaid Services (CMS). CMS demands it before a provider is eligible for Medicare or Medicaid reimbursement. In addition, the majority of hospitals work to get Joint Commission certification as a sign of their dedication to offering high-quality care.

How Does the Provider Credentialing Work?

The process of credentialing and enrolling providers involves multiple steps. Every health plan a provider wants to sign up with requires them to undergo this procedure.

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  1. The doctor provides all necessary information, such as contact details, a current resume, education and training histories, licenses and certificates, affiliations with medical groups and hospitals, Board certifications, sanctions or history of malpractice, evidence of liability insurance, and peer references. 
  2. The insurance company or provider organization verifies that all the data is accurate and current.
  3. Contacting payers on a frequent basis for follow-up after filing a request for credentialing.
  4. Data entry and labeling enable the payer to identify providers in its database. 
  5. Updating provider information in compliance with processes and standards. 
  6. If no issues arise, the provider group or health plan grants the provider a certification.

 

The time it takes to complete the physician credentialing procedure might range from 30 days to six months or longer, especially if the information is faxed or mailed.

Then Why Do You Need A Provider Credentialing Service?

1. Protects Your Patients 

Patients never settle for less while searching for medical services. That is why most patients try to verify the providers before seeking medical care. The key documents most patients shall check before going to any healthcare practitioner must include the OFAC, National Abuse Registry, and Social Security Death Master File.

2. Prevents Lawsuits Against Practices

 

Although the fundamentals of compliance and best practices are covered in the credentialing process for providers, there are still some situations where things are out of the providers’ control that straightaway lead to lawsuits.

3. Providing revenue protection to healthcare organizations

 

Compliance with state and federal requirements is ensured using suppliers with the appropriate credentials. The payer can withhold payment when a healthcare organization applies for reimbursement from Medicare or Medicaid for the services rendered by an excluded physician. If the reimbursement has already taken place, the clinic or practice may be subject to fines and civil monetary penalties.

By using provider credentialing and enrollment services, you can:

  • Real-time verification of enrollment and credentialing status; 
  • maximization of income through reducing revenue leakage
  • Boost patient referrals; 
  • Reduce paperwork and application fill-outs; 
  • Identify provider trends; 
  • Decrease denials; 
  • Build connections with various payers; 
  • Ensure that your payer data is current. 

Conclusion 

Start the credentialing procedure as soon as possible to get results faster. You might save months by beginning the credentialing at the early stage. You must be aware that credential verification could take three months if you intend to hire a new physician for your practice. As a result, you might not even be able to send an employment offer until the verification procedure is finished. No matter how you go about it, you must ensure the credentialing process is enduring. You should consider your options before starting the credentialing procedure. The optimum route to credentialing is determined by the resources available to your facility and your credentialing budget.

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