10 Best Practices to Ensure Successful Credentialing

By Justine Marquard, Credentialing Specialist, Physicians Group Management

Whether you operate an in-house credentialing program or outsource your credentialing, there are many best practices to follow to ensure your program delivers timely credentialing and re-credentialing results that do not keep your physicians from providing care. Here are 10 helpful tips to help ensure your physicians are successfully credentialed and re-credentialed, and provide the care appropriate for their participation status.

1. Make sure your providers' CAQH profile is current. The CAQH Universal Provider Datasource is a free online database for providers. It houses physician profiles that include information on education, training, licensure, DEA certificates, board certificates, insurance and more. Every three months, providers are required to reattest to the accuracy of the information in CAQH or must update their profile accordingly.

Insurance companies including Aetna, Cigna and UnitedHealthcare will pull provider profiles from CAQH and review the information essentially as the application for credentialing. But if physicians do not reattest to the accuracy of their profiles every three months, the insurance companies cannot pull the profiles to begin the credentialing or re-credentialing process. Once a profile is outdated, it delays the beginning of these already lengthy processes.

2. Make sure your providers' CV is current, and includes details of education and work history in month/year format. Some insurance companies require access to providers' curriculum vitaes. They can be uploaded to CAQH, and should be presented in month/year format. The CV must be in this format and kept current or this will likely lead to credentialing delays.

3. Provide your credentialing specialist with complete and accurate information. If you decide (like many providers do) to outsource your credentialing, you must still remain an active participant in the credentialing and re-credentialing process even if most of the heavy work is taken off your shoulders. Part of your responsibility is to ensure the information you provide to your credentialing specialist — whether this individual is a coworker or contractor — is complete and accurate.

If your credentialing specialist is provided with an incorrect NPI number, for example, and this information is submitted to insurance carriers, the specialist will eventually need to correct it, which takes time and claims will be denied for incorrect information on file which will interrupt cash flow. It can take a few weeks for carriers to update their records with a new NPI, and will likely take a few more weeks to then correct this figure. It may also take some time for your credentialing specialist to determine which carriers received the incorrect NPI.

4. Provide current copies of paper documents. For those insurance companies that still require paper applications, your credentialing specialist will need to submit hard copies of licenses, DEA certificates, malpractice documents and other documents, and all of these need to be current. If any of the documents are expired or include incorrect information, this will delay the credentialing process as it takes time to receive and submit updated versions of these materials. If any of these documents are submitted to carriers, it will further delay the process as the insurance companies will then need to reprocess the new documents.

5. Assemble a list of carriers you currently participate with. There is tremendous value in having a detailed chart of the carriers your providers participate with, which is why we assemble and provide our partners with such a grid. The chart includes the provider's name, NPI number, tax identification number, a list of all insurance companies he or she participates with, effective dates and other related information.

This grid is a helpful reference tool schedulers can scan to check coverage when patients call in to make appointments. It also helps with staying atop re-credentialing deadlines and ensuring your credentialing specialist doesn't spend time working to get your providers in network with carriers with which your physicians are already credentialed.

6. Identify insurance carriers you are interested in participating with. Identifying which carriers your physicians want to participate with removes the need for any guesswork on the part of the credentialing specialist. It's also important to note that each state has different carriers, and your credentialing specialist may not be familiar with all of them, so providing your specialist with a list will make the credentialing process go smoother and faster.

7. Always forward correspondence regarding credentialing to your credentialing specialist. And make sure you forward the correspondence along promptly. This will help to avoid disruption or termination in your participation due to missed requests for information. If you're unsure about whether your specialist needs to receive a correspondence, you will be better off forwarding it and letting your specialist determine whether it's relevant.

8. Know your providers' participating effective date before scheduling patients. If physicians are not participating in an insurance plan until June 1 but see a patient on May 31, they cannot bill the insurance company as a covered entity. It is critical to know the effective date of when your physicians will have participating status and go in network.

When a physician is not affiliated with the health insurance company of the patient requesting treatment, it is critical to...

9. Confirm if the patient has out-of-network benefits. If a patient has out-of-network benefits, physicians can bill for the care they deliver as an out-of-network provider.

10. Be patient with the credentialing process. Credentialing is a long, complex process with many components and steps. You should be in regular communication with your credentialing specialist about the progress of the credentialing and re-credentialing of your physicians. Make sure you receive routine updates, and don't hesitate to ask any questions.


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