7 Essential Stages in the Provider Credentialing Process You Need to Know
As a healthcare organization or practice, you are probably aware of the provider credentialing. In simple terms, the process of provider credentialing is an assurance that the medical providers are qualified enough to provide healthcare services.
Whether you own a small-scale clinic or a large-scale healthcare organization, understanding the essential stage in provider credentialing holds importance. Moreover, provider credentialing can directly influence revenue cycle management as it may lead to getting proper reimbursements.
This blog post will walk you through provider credentialing in healthcare, its importance, and the 7 stages of the provider credentialing process.
What is Provider Credentialing in health care?
Provider credentialing is one of the major processes in health care that assures a health professional is qualified to practice and conduct needed care at the right level.
This means it ensures the education, training, experience, licensure, and other primary qualifications of a provider are adequate to render quality patient care. This procedure is deemed fundamental for both patients’ safety and the reputation of healthcare organizations.
- Primary source verification needs to be done for providers in terms of education, training, and board certifications.
- Ensure that providers are licensed to practice in their respective fields with an active unrestricted license.
- Detailed criminal history checks, malpractice claims, and disciplinary actions against them are carried out.
- Continuous verification is required to maintain credentials that help keep providers in good standing.
This process keeps other uninformed individuals from practicing and therefore ensures patient protection, among other reasons that help maintain the integrity of healthcare practice. It also plays an important role in the revenue cycle because most insurance companies and government programs alike require credentialed providers for them to reimburse.
So each provider would need to be credentialed with every insurance company they bill, which makes them a very time-consuming but important part of healthcare operations.
Related: A Guide to Credentialing in the Medical Billing Process
Why Provider Credentialing is Important for Healthcare Practice
Provider credentialing is one of the significant processes in healthcare that allows for assurance in standards assuring safety and effectiveness in care. This is far from being just a formality but a foundation of quality assurance in the practice of healthcare.
- Credentialing assures that healthcare professionals have the working skills and knowledge to care for patients, greatly reducing medical errors.
- Many states and several accrediting agencies require credentialing as a means of ensuring that providers operate within legally and professionally recognized standards.
- Insurance carriers may require credentialing for providers to be reimbursed for their claims. Without proper credentialing, a given individual may face claim denials that could affect financial stability.
- A well-credentialed staff adds to the prestige of practice by instilling confidence in the patients, ensuring that it is acknowledged as credible and competent.
Proper credentialing of providers will support the practices of protecting patient care, meeting regulatory requirements, ensuring financial integrity, and maintaining professional integrity. This process, in turn, will support quality healthcare delivery and help maximize overall healthcare efficiency.
7 Essential Stages of Provider Credentialing Process
Here’s a step-by-step guide to understanding the provider credentialing process.
Step 1: Pre-Application Preparation
Therefore, healthcare providers should have the documents and information necessary to begin the credentialing process before entering into such. Such information includes but is not limited to a copy of:
- The current medical license
- Current board certification
- Malpractice insurance
- DEA registration
- Any other relevant certificates.
It’s also advised that Providers prepare in as much detail a professional history that describes education, training, work experience, and disciplinary actions taken against them.
This shall be necessary because bad or incomplete information may delay the Credentialing Process.
Step 2: Submission of the Credentialing Application
Once the documents are all ready, then an application for credentialing will be submitted by the provider to the healthcare organization itself or a third-party credentialing agency.
The application will be quite comprehensive; it will encompass personal information, professional qualifications, work experience, and professional references. Care providers need to be attentive when filling out this application, or even minimal mistakes could lead to possible delays or refusals.
Step 3: Primary Source Verification
Primary source verification by the credentialing body involves, among other processes, making calls to institutions and organizations where the provider obtained his or her credentials to confirm that these documents are real. It would entail verification of:
- Medical school diplomas
- Residency and fellowship training
- Board certifications
- State medical licenses
All this would be aimed at ensuring the validity of the qualifications held by the provider and that they meet the set standards.
Step 4: Background Check and Evaluation
In addition to the verification process, credentialing also covers background screening of the provider on his review of malpractice history, criminal records check, and disciplinary actions against him by a licensure board or professional organization. It aims at ensuring that the provider’s professional background is clean and acceptable.
Step 5: Credentialing Committee Review
The information on the credentialing application is presented to a credentialing committee upon completion of the primary source verification and background check. This would typically consist of a panel made up of knowledgeable professionals in healthcare who would thoroughly analyze the application of the provider.
They analyze the application against the requirements within the organization regarding whether the provider can provide care. If the committee identifies concerns or areas where additional documentation might be required, they may contact the provider for more information or clarification.
Step 6: Approval and Privileging
If the credentialing committee votes to approve, the provider is granted privileges to practice within that healthcare organization.
Privileging refers to the specific services or procedures the provider is authorized to perform within the organization. The scope of these privileges is determined by the provider’s qualifications, experience, and the organization’s needs.
Step 7: Recredentialing and Ongoing Monitoring
Credentialing is not a one-time event, but it involves re-credentialing periodically and monitoring on an ongoing basis. Typically, healthcare organizations require providers to get re-credentialed every two to three years.
This would involve updating credentials, running new background checks, and verifying that the provider continues to meet the standards. Ongoing monitoring may involve periodic performance reviews and tracking of any new disciplinary action or malpractice claims.
Learn More – Medical Credentialing
Need Help in Credentialing in Medical Billing? CapMinds will assist you
Credentialing in the medical billing process can be complex, especially for healthcare providers. However, it is associated with various challenges that may affect healthcare practice’s financial health.
At CapMinds, we are bringing a comprehensive solution to make credentialing in medical billing easier.
Our team of experts will ensure that the whole credentialing in the medical billing process is smooth without any mistakes. Utilizing our service, healthcare providers can ensure:
- 24/7 Support: Always available for your queries.
- Dedicated Client Manager: Personalized service for your practice.
- Efficiency and Accuracy: Streamlined billing, fewer claim denials.
- Financial Optimization: Maximize revenue, and correct underpayments efficiently.
- Enhanced Cash Flow: Timely collections, and improved financial management.
- Compliance and Security: Adhere to industry standards always.
We help you to gather all the necessary information accurately, complete the application form, and submit the credentialing essentials to payers, thereby better clinical and service expansion.
We also have a dedicated client manager who will be exclusively assigned to you. And the team will be available around the clock to assist with your queries.
“Reach out to CapMinds to make your credentialing in the medical billing process more effective”