In this article we dive into practical, actionable insights to help streamline the credentialing process, reduce administrative overhead, and guarantee ongoing compliance.

Credentialing is crucial for maintaining regulatory compliance, ensuring operational efficiency, and safeguarding patient safety. Yet, for many healthcare providers, the credentialing journey is fraught with complexity and administrative challenges that can lead to delayed services, revenue loss, and compromised care quality.

In this article, we dive into practical, actionable insights to help streamline the credentialing process, reduce administrative overhead, and guarantee ongoing compliance.

The Three Essential Phases of Credentialing

Credentialing is a continuous process that ensures providers can offer the best care possible. Providers must undergo credentialing in several scenarios:

• When initially joining a practice or launching a new one.
• To periodically maintain existing credentials.
• Upon transferring to a different practice group.
• When registering with a new insurance provider.

Typically, credentialing is a demanding process, taking between 90 to 120 days to complete due to the vast amount of information that needs collection, submission, and verification. The timeframe may extend beyond 120 days if there are delays from the insurance company or if the documentation provided is incomplete and requires resubmission.

The credentialing process for providers comprises three distinct phases:

• Credentialing: The clinician's qualifications are obtained, verified, and assessed, determining their ability to provide care within a healthcare organization.

• Privileging: This step involves authorizing a healthcare practitioner to perform specific patient care services within an organization, based on their credentials and performance.

• Enrollment: In this phase, the practitioner applies for inclusion in health insurance networks, which will allow them to bill for their services.

Recredentialing, or re-enrollment, is also a periodic necessity. With credentials having an expiration date based on market standards, practitioners must re-credential to demonstrate their knowledge and skills are current in a rapidly evolving medical landscape.

Notifications for recredentialing are sent out via email or paper mail, with a specified deadline. Practitioners should initiate the recredentialing process promptly upon receiving these notifications to avoid any interruption in their practice.

Understanding Credentialing and Privileging

Credentialing and privileging are fundamental for maintaining the excellence and safety of patient care. The steps that ensure providers are comprehensively vetted include:

• Verification of Credentials: The process starts with the rigorous verification of a provider's credentials, where MSPs validate qualifications, licenses, and education.

• Committee Assessment: The Credentials Committee then evaluates the provider's qualifications and recommends any necessary follow-up actions.

• Departmental Review: Next, the Department Chair or Service Chief reviews the provider's fit for the department's needs and their potential contributions to the team.

• Executive Evaluation: The provider's qualifications undergo a detailed evaluation by the Medical Executive Committee, considering the provider's fit for the clinical environment and specialty services.

• Governing Body Finalization: The governing body of the healthcare facility then makes the final decision on the provider's privileging, based on all prior evaluations.

• Notification and Appointment: The MSP issues an official appointment or decision letter to the provider, formalizing their credentials and care authority.

• Onboarding and Integration: The last step involves onboarding the provider into the facility's systems, a multi-departmental effort to equip the provider with the necessary tools and knowledge for service delivery.

Each of these steps is pivotal in upholding high standards in medical care and patient safety, forming a thorough and rigorous process that healthcare providers must navigate with precision and care.

Dispelling Common Misconceptions in Credentialing and Privileging

Misunderstandings can lead to setbacks, delay patient care, and affect the seamless commencement of your role.

Myth 1: Credentialing Starts After You Accept the Position

Many believe credentialing only begins post-job acceptance, but in truth, this critical process should commence prior to acceptance. This foresight allows any potential documentation issues to be rectified well ahead, safeguarding your start date. Vigilance is key, especially if others submit information on your behalf; watch for "red flags" that might need further clarification.

Myth 2: The Offer Letter Date Is Your Patient Care Starting Line

The date on your offer letter is not a guarantee of when patient interactions will begin. It’s merely provisional, dependent on successful credentialing and privileging clearance. Realistically, you will engage with patients only once these administrative requirements are fully met and approved.

Myth 3: Human Resources Applications Double as Credentialing Records

A common fallacy is that paperwork processed by Human Resources is adequate for credentialing purposes. The truth is, credentialing and privileging require far more detailed and specific information. Merging these processes could cause substantial hold-ups in the validation of your professional credentials.

Myth 4: Employment and Peer References Serve the Same Purpose

It's essential to discern between employment references, which reflect on your work history and character, and peer references, which are testimonials to your clinical competence. Both types of references are indispensable and play different roles in the comprehensive review of your professional standing.

Myth 5: Delegated Submission Mistakes Aren't Your Responsibility

A critical error is assuming that delegated tasks, such as submission of documents, absolve you of responsibility for inaccuracies. As the provider, it is incumbent upon you to ensure all submitted information is correct. Errors in this data can seriously hinder your ability to practice.

Awareness and understanding of these key aspects of credentialing and privileging can significantly influence your transition into a healthcare role.

4 Key Tips for Self-Credentialing

Credentialing is especially critical for small practices aiming to self-credential, as it can influence a patient's choice based on insurance coverage.

Tip 1: Understand State-Specific Regulations

Grasping the credentialing requirements specific to your state is crucial. Some states may permit billing during the credentialing process, while others may not. Be aware of reciprocity agreements that could expedite your credentialing with certain payors if you're already established with them elsewhere.

Tip 2: Familiarize Yourself with Credentialing Timelines

The time frame for credentialing approval can vary, often ranging from two to four months. To ensure financial viability, your credentialing should be finalized before services are billed.

• Begin the credentialing paperwork ahead of finalizing contracts to reduce waiting periods.
• Determine how insurance companies backdate credentials, as some may recognize the submission date as the start date.
• For immediate needs, a single case agreement could be a temporary solution.
• Promptly submit credentialing documents for new hires to avoid any lag.
• Complete and accurate documentation is key to preventing processing delays.

Tip 3: Acquire Necessary Documentation for Small Practices

Each insurance company may have its own set of documentation requirements. Common necessities include CPR certification, RBT certification, and comprehensive background checks.

• Manage the CAQH profile diligently as inaccuracies here are frequent delay culprits.
• The NPI number is essential and takes a short time for application.
• Ensure certifications like First Aid and CPR are current.
• Verify state licensure and have an updated resume along with copies of certifications or transcripts readily available.

Tip 4: The Importance of Follow-Through

After submission, the follow-up process is critical to ensure your application is being processed. Insurance companies may not proactively update you on the status of your application, so it is important to:

• Regularly check in on the status of your application.
• Aim to confirm an effective date for billing as this signals the completion of the credentialing process.
• Continue monitoring the process until successful claim payments are confirmed.

Gathering all the necessary information, understanding regulations across different states, and consistently following up are key actions that will lead to obtaining that all-important effective date. Once credentialing is achieved, your practice can move on to contracting.

Exploring Alternatives to Traditional Manual Credentialing

The evolution of healthcare facilities, particularly those in growth phases, necessitates a shift away from traditional manual credentialing methods. Modern healthcare operations are increasingly turning to outsourcing and advanced credentialing software solutions to streamline this essential function.

Embracing Outsourcing for Physician Credentialing

Many large-scale healthcare operations blend in-house credentialing teams with outsourced services, creating a hybrid model designed to minimize delays and optimize documentation management.

Outsourcing emerges as a strategic choice for multiple reasons:

• It serves as a robust support system, particularly when in-house teams are understaffed due to turnover or leaves of absence.
• Comes with a dedicated workforce skilled in managing these processes, boasting a depth of experience and a structured approach that can greatly enhance efficiency and accuracy.
• Can reduce the administrative load, shifting the burden of staffing management off the facility.

However, outsourcing is not a one-size-fits-all solution. It is critical for facilities to thoroughly vet potential vendors to ensure they select a partner that not only provides regular updates but also aligns with their values and standards of quality. While outsourcing can offer cost savings, facilities should regularly assess these partnerships to ensure they remain financially advantageous.

Leveraging Credentialing Software for In-House Efficiency

For facilities that prefer to keep credentialing in-house, investing in robust physician credentialing software is key. Here’s what to look for when evaluating options:

• User-Friendly and Compliant: The software should be intuitive and comply with industry regulations.
• Automation and Centralization: It should streamline the process, allowing for a paperless approach, and enable all actions, from requests to document tracking, to be managed centrally.
• Expiration Tracking: The system must proactively track important dates and automatically alert the facility and providers of upcoming expirations.
• Customization: The best software solutions offer customization options that conform to a facility’s specific needs.
• Accessibility: Opting for cloud-based or SaaS solutions offers the flexibility of access from various devices, facilitating real-time updates and remote management.

Whether choosing to outsource or to enhance in-house operations with software, the goal remains the same: to make credentialing more efficient, less prone to error, and aligned with the evolving needs of dynamic healthcare environments.

Credsy: The Comprehensive Credentialing Partner

Credsy is a one-stop shop for facilities to efficiently manage documentation. With the ability to request, sign, upload, customize, and track essential documents all in one digital space, the days of navigating through stacks of hard copies are behind you.

Credsy stands out by offering automation and centralization for the credentialing process, greatly reducing the potential for human error and increasing the speed at which tasks are completed. The software is programmed to send automated notifications, keeping your facility and healthcare providers informed of document expirations, ensuring continuous compliance and safeguarding your operation's credibility and revenue.

User-friendliness is at the heart of Credsy's design, making it accessible for users of all tech proficiencies. But the true measure of its impact is best experienced firsthand. We invite you to witness the capabilities of Credsy in action—schedule a demo and explore how it can revolutionize your credentialing processes.