The Fact About Insurance Credentialing Process

What is the insurance credentialing process?

Credentialing is a confusing and overwhelming process for many healthcare practices. And while the process is complex and time-consuming, it is absolutely necessary for any practice or provider to become “legitimate” with insurance companies.

The credentialing process enables healthcare practices to acquire the proper credentials and register them with insurance panels (frequently called payers) to be considered “in network.” Basically, credentialing allows healthcare practices to bill insurance companies for the procedures and treatments they offer.

Who needs insurance credentialing?

Think of credentialing as a verification process. Credentialing allows insurance payers to fully trust a provider or practice. This means everyone needs to go through it, and they need to go through it often. For example, if a new provider is fresh out of school, she needs to be credentialed. If a provider has moved to a new state, he needs to be re-credentialed. If a provider decides to go independent after working with a previous employer that managed her credentialing, she needs to be credentialed. Or, if a single provider or group of providers wishes to start a new practice, they, along with the practice, need to be credentialed.

Additionally, whenever there is a change in the services provided at a practice, there is a change in credentialing needs. This process is paperwork-intensive and requires consistent and diligent upkeep. Usually, it makes sense for a provider or practice to outsource their credentialing needs.

How does the process work?

After finding the right outsourced credentialing services to streamline the process, the next three steps for a practice or provider are simple.

1. Prepare and maintain your documentation.

While different insurance payers have different documentation requirements, there are some industry standards that never change, such as your tax identification number, phone number, and practice address. It is also extremely important to register or update an existing CAQH (Council for Affordable Quality Healthcare) profile.

The CAQH is a simple database that any provider can log into to create and maintain a professional profile. This profile is essential to have before beginning any credentialing process because it is a one-stop shop for insurance panels to view a provider’s education, licenses, references, and more. A lot of payers use a practice’s CAQH profile as the main portion of a credentialing application. It is crucial to maintain any licenses or malpractice inspections. This can easily be updated on a live CAQH profile at any time, but four times a year, CAQH will send you an alert to “re-attest” all your information.

As for other documentation, it is vital to make sure your resume is current. This includes listing any new practice or service you wish to begin credentialing, even if you have not begun seeing patients yet. You may also need to obtain an NPI (National Provider Identifier) number. You will need Type 1 to be credentialed as an individual or Type 2 to be credentialed as a practice. A credentialing service specialist will be able to help you quickly navigate through all your documentation needs.

2. Choose payers to be in network with and start the application process early.

Locate the most popular insurance payers in your area that you wish to be in network with. Check with other practices, major institutions, and hospitals to see what insurance networks they are partnered with, including government networks.

Once you have selected the payers you wish to register with, start the process as soon as possible. This cannot be stressed enough. Credentialing processes can take anywhere from 3 to 6 months. Government networks often take even longer, and any slight mistake can delay the opening of your practice. The sooner you start, the better.

Also, keep in mind that some networks require prerequisite credentialing. For example, you cannot join Medicaid until you are enrolled in Medicare. If it takes 6 months to enroll in Medicaid and then 6 months to enroll in Medicare, that is a total of 12 months for two networks! Again, start early.

3. Submit your applications and continually follow-up.

This is where an outsourced credentialing professional comes in clutch. A credentialing specialist will be able to follow-up and advocate on your behalf. They will make sure that the insurance payer receives all necessary documentation, look for ways to quicken the process, and make constant contact with the payer to ensure that your application does not get dropped while you focus on your practice.

Never wait to re-attest your information, make sure to alert your credentialing specialist of any information changes, and follow-up, follow-up, follow-up.

Continuing Action

Credentialing with insurance companies is not an easy process, but with the right preparation, materials, and persistence, you can achieve success. Even then, every provider and practice must renew their credentials from time to time. Knowing when to renew is crucial. A credentialing specialist can help you with this and more. With these steps now in mind, you are well on your way to getting credentialed.