Your Questions on Medical Credentialing Answered


Questions on Medical Credentialing Answered

If you have any concerns on medical credentialing for your medical practice, this blog post will have you covered. Read on.


What is medical credentialing?


Medical credentialing is the verification process that must be performed for all new medical practices, physician hires at existing medical practices, and for physicians locating to a new state where the physician does not have a practicing license. Existing physicians must be re-credentialed at least once in three years, although some payers may require physicians to re-credential sooner than that.


The credentialing process involves verifying the physician’s medical school education and training, residency, license, work experience, certifications, other training, affiliations, malpractices, and adverse clinical occurrences. Once credentialed by a payer, the physician is then authorized to provide services to patients who are members of the payer’s medical insurance plans. Payers are entitled to refuse payments to physicians not credentialed and enrolled with them.


The credentialing process is performed by a Credentials Verification Organization or CVO, whose responsibility is to contact the educational institutions and training bodies from where the physician has either studied, done residency, or obtained additional qualifications. Similarly, previous employers and hospitals are contacted for confirmation of work history.


Medical credentialing is also known as physician credentialing, provider credentialing, or doctor credentialing. Although medical credentialing is mainly associated with physician credentialing, similar but less extensive credentialing processes are in place for nurses and healthcare providers.


There are three different stages of credentialing:

  • Provider credentialing – It is the actual verification of the information provided by the physician.
  • Provider enrolment – The payer approves the physician as an in-network provider. The physician is then authorized to treat patients who have insurance from the same payer.
  • Privileging – It is the approval given to providers to perform specific medical procedures based on demonstrated competency.

For a medical practice, medical credentialing is important for compliance and for authenticating the information provided by new physician hires. Since credentialing is intrinsically linked to insurance pay-outs, timely medical credentialing is vital for revenue cycle management. For patients, medical credentialing ensures the maintenance of specific standards of healthcare at medical practices.


When is medical credentialing required?


Medical credentialing is not a one-time exercise for a medical practice or a physician. Physicians typically undergo medical credentialing under the following circumstances –

  • Starting a new medical practice.
  • Joining a new medical practice.
  • Joining a new medical practice group.
  • For enrolling with new payers.
  • For re-credentialing as per the intervals required by payers.


How long does medical credentialing take?


The process of medical credentialing from the date of submission of provider documents can take anywhere between 60 to 90 days. In some cases, it may even go up to 120 days.


What is CAQH’s role in credentialing?


CAQH, or the Council for Affordable Quality Healthcare, is a non-profit organization set up by the leading national insurance companies to streamline the administrative processes between payers, physicians, and patients. It is a voluntary online portal that physicians and other healthcare professionals (in all 50 states and the District of Columbia) can access to update their information and documents in a secure database. The data is accessible to participating insurance companies for evaluating physicians for credentialing. The CAQH portal eliminates the paperwork involved in credentialing with multiple payers.


What are the documents required for medical credentialing?

Here is a list of documents and information required from a provider for medical credentialing.


Identity proof

  • Government-issued photo identification.
  • Form I-9 acceptable documents.
  • Employment authorization document for non-citizens.

Professional education & training

  • Documentary proof of all medical education qualifications, training, residency, medical licensing exams, and any other relevant degree.
  • Explanation of gaps in education if any.
  • ‘Educational Commission on Foreign Medical Graduates’ validation.

Military service details

  • Complete details of your military service and DD214 (Certificate of Release or Discharge from Active Duty).

List of professional license

  •  Details of all the professional licensure obtained in different states.

DEA registration number and Controlled Dangerous Substances Certificates

  • Copies of your DEA, DPS, and/or CDS certificates, along with details of issuing state, status, registration number, and issue and expiration dates.

Affiliations and career history

  • A comprehensive chronological role listing of all the medical facilities the provider has worked at or had clinical privileges.

Other details 

  • Taxpayer Identification Number (TIN)
  • National Provider Identifier-2 (NPI-2)
  • Complete disclosures on criminal background, sanctions, malpractice cases open and closed, National Practitioner Data Bank report, and current malpractice insurance certificate.
  • Declaration of any health issues that may affect your ability to work.
  • References with contact information.


Tips to improve medical credentialing at your medical practice


Medical credentialing is time-consuming and complicated. But you can streamline the process to ensure that you waste minimal time waiting for your team of physicians to be approved by payers.


While the CAQH continues to offer the option of submitting a paper application for medical credentialing, electronic credentialing will save you considerable time. As soon as you have identified a physician for hire, check the list of payers that have approved the physician and which insurance companies you need to approach for credentialing. Share the list of insurance companies you’d want the physicians to apply to, along with the links for online form submission, as well as the completed W9 form for your medical practice.


Guide the provider in filling the credentialing form. For instance, unexplained time gaps in the physician’s work history can result in the suspension of the application processing. Ensure that the physician’s resume is submitted as per the required date format. Keep a tab on where each application is in the medical credentialing process and help the physician mitigate any lapses in information submission.

Some credentialing experts recommend that medical practices ask new physicians to join 120 days from submitting credentialing paperwork.


What are the advantages of outsourcing medical credentialing to a specialized medical billing service?


Ensuring that your medical staff and physicians are credentialed is vital to the financial health and reputation management of your medical practice. Private insurance companies, as well as Medicare, and Medicaid demand proof of credentialing before approving payments for patient services. Having fully medically credentialed nurses and doctors will instill confidence in your medical practice. Credentialing ensures that the medical staff you hire are trained, experienced, and competent. On a broader level, credentialing is essential for the maintenance of health and safety standards in the U.S. medical industry.


However, as discussed above, medical credentialing is a painstaking process that requires attention to detail. Any missing information or errors in data presentation can lead to additional delays in the prolonged approval process. So, it makes sense to outsource medical credentialing to a team of credentialing experts who are aware of what it takes to get approvals and are responsible for tracking any delays in approval. Also, the cost of medical credentialing outsourcing is negligible compared to the immense revenue benefits of getting your new hires approved by payers.


Medical practices have had to mobilize resources and staff quickly to adjust to the new realities of healthcare post the COVID-19 pandemic. Other industry trends, especially the increased compliance regulations and higher patient payment responsibilities, have already amplified the non-care aspects of managing a medical practice. More medical practices are turning to experienced partners to help ease the administrative aspects such as medical coding and billing, medical credentialing, and patient billing. If you are considering medical billing outsourcing for your medical practice, or if you need assistance with medical credentialing, we’d be happy to help.

Parul Garg, CEO and co-founder of PracticeForces, has significantly contributed to the growth of over 1,000 U.S. medical practices through her expertise in medical billing and coding since the company’s inception in 2003. With a background in Computer Science and an MBA in Human Resources, her leadership and AAPC-certified coding skills have been pivotal in managing the company’s operations effectively.

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