Provider Credentialing: 2023 Update

January 23, 2023  | By dailycare

Credentialing is a necessary process that healthcare systems must undertake to verify the professional background and qualifications of their providers.

As we enter 2023, you may have some questions about provider credentialing.

We’ve put together a 2023 update on why credentialing is essential and steps your healthcare system can take to streamline the process.

Why Credentialing is Important

Medical credentialing is an essential process that verifies healthcare providers’ qualifications and professional backgrounds. Therefore, it is crucial for healthcare facilities to ensure that their providers have proper insurance reimbursement credentials and provide broad patient care access.

The process is vital for physicians and other healthcare providers such as: 

  • Hospitals
  • Health Agencies
  • Dentists
  • Physical Therapists
  • Licensed Massage Therapists
  • Counselors
  • Psychologists 

To accept Medicare and Medicaid, facilities must comply with guidelines set by the Centers for Medicare & Medicaid Services (CMS) and The Joint Commission on Accreditation of Healthcare Organizations. 

Each state also has credentialing requirements that you must follow to reduce liability in the face of malpractice claims. 

This process is crucial for providing safe, high-quality care for patients and the financial stability of healthcare providers.

Critical Steps For Streamlining the Provider Credentialing Process

Here are five steps your organization can follow to prepare for the provider credentialing process. 

Assemble the Required Documentation

As you embark on the healthcare credentialing process, it’s important to note that each insurer has different requirements for documentation and forms. To ensure that your applications are complete and accurate, list all insurance providers you plan to file with and gather all necessary documents. 

These may include but are not limited to

  • Name
  • Social Security Number
  • Demographic Information
  • Education
  • Residency Information
  • Specialties and Patient Focus
  • Proof of Licensure
  • Career History
  • Claim History
  • Proof of Insurance
  • Information Regarding Your Healthcare Facility

Your provider may have reported some of this information in their resume and application. Therefore, it’s essential to double-check and verify its accuracy to ensure the approval process is completed on time.

A Person Handing Out A Document

Verify the Information is Accurate

As you gather the required documents and start individual applications, it is crucial to keep in mind that the quality and accuracy of the information are critical. 

In addition, before submitting any application, it’s vital to conduct a thorough background check on the provider to ensure they have the necessary qualifications. And that there is no history of disciplinary actions or malpractice claims. 

You can verify the educational history, licensing, board certification, and reputation through healthcare organizations such as the American Medical Association (AMA), the Educational Commission for Foreign Medical Graduates Certification (ECFMG), and the American Board of Medical Specialties.

Additionally, it is important to review the provider’s history of credentialing, privileges, and insurance claims. This history can help identify any previous issues that could impact the approval process. It is also important to list any sanctions recorded with the Office of Inspector General (OIG) to ensure that the provider has not been involved in fraudulent activities.

It is also important to note that any errors in the submitted information can cause issues and delays in the approval process. For example, if past employers have not quickly and accurately verified months and dates of employment, revising the application with the correct information can delay the approval process. 

Likewise, incorrect phone numbers for references or past employers can create delays or rejections. Omissions of past malpractice claims could also be disqualifying.

Once you have assembled and verified the documents, they should be presented to facility leadership for determining specific privileges to be granted to the new provider. Again, this information is vital for the credentialing application. 

The facility can manually verify provider information or use alternative methods like credentialing software or outsourcing to a credentialing service to save time and money.

Complete the Council for Affordable Quality Healthcare (CAQH)

Several major healthcare insurers require partner facilities to apply for credentialing through the Council for Affordable Quality Healthcare (CAQH) in addition to completing their individual applications

Once your facility has filed an application with an individual insurer, they will provide a CAQH number and an invitation to apply. 

The application can be completed on paper or online, which is more efficient as it eliminates the need for manual data entry. However, it is crucial to ensure that the information provided is accurate and complete to avoid delays in the approval process. 

Additionally, facilities will need to re-attest the accuracy of provider information four times a year to maintain continuous insurance eligibility.

Wait for Verification and Follow-Up

Once the application has been assembled and submitted to insurers, it’s time to wait for their approval. 

Credentialing can be lengthy, and experts suggest allowing yourself 120 days for completion. However, most credentialing can be completed within 90 days

In case of serious issues, the process may take even longer.

It is important to follow up consistently with the insurance company to ensure timely approval. In addition, building relationships with key personnel such as leadership, executive assistants, and other staff can help to ensure that the application process moves along smoothly. 

Following up via phone call is more effective than email. If additional information is required, it should be compiled and verified promptly.

Prepare For Recertification 

Your provider will eventually receive their insurance panel credentialing. However, it is important to note that this ongoing process often requires additional work

If errors in an employee’s information are discovered, it’s critical to notify insurers immediately. If the insurer notices the erroneous information before a formal correction is submitted, it could be grounds for revocation. 

Most providers require re-credentialing every three years. Credentialing software can help manage the process and notify you when renewing a specific provider’s credentials is time. 

Additionally, insurers should also send a notification after three years have elapsed. It is important to respond promptly to ensure that your provider can continue providing patient care without interruption.

A Doctor in Surgical Scrubs With a Stethoscope

Provider Credentialing is An Ongoing Process

The medical credentialing process is essential for ensuring that your healthcare facility has adequate staff levels. And that your healthcare providers are qualified and authorized to provide patient care. 

The process can be time-consuming and tedious, but following the proper steps and guidelines can help to streamline the process. It is also important to remember that credentialing is an ongoing process that requires additional work down the line, including regular re-credentialing and addressing errors in employee information in a timely manner. 

Utilizing credentialing software and outsourcing can also help to save time and resources. 

Overall, the importance of healthcare credentialing cannot be overstated, as it helps to instill confidence in patients, reduce medical errors, and ensure reimbursement.

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