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Medical Credentialing: What Is It & Why Is It Important for Reimbursement?

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Medical Credentialing: What Is It & Why Is It Important for Reimbursement?

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Without proper medical credentialing, a medical practitioner legally cannot work at a hospital or partner with insurers.

Having medical staff credentialing training is crucial to ensure staff properly attain and maintain physicians credentials. Only a new physician or practitioner who is credentialed is allowed to see patients, receive insurance reimbursements, and treat hospital inpatients. Fail to attain on-time credentialing and the new staff will fail to meet the practice’s financial goals.

Medical credentialing is the process of compiling data about a medical practitioner, his primary source verification, and committee reviews. Credentialing assures the patients of their healthcare provider’s expertise.

Whether you go to credentialing workshops, take medical credentialing training courses online, or do anything in between, it’s important to know exactly what credentialing is and why it’s so important. So, let’s have a look:

What Does Medical Credentialing Mean in Healthcare? 

Medical credentialing is, in short, an evaluation of a medical provider’s license, their training, experience, competence, specialty certificates, malpractice history, and more.

It’s essential for a provider’s credentials to always be current and accurate, and for them to follow the standards and rules implemented by the National Committee for Quality Assurance and The Joint Commission.

Since credentials must be current, medical practitioners must go through the process of medical credentialing multiple times throughout their career. The whole process is a bit long, taking anywhere from 3 to 5 months, so a credentialing specialist or biller typically starts the process either just before a medical practitioner is hired, or as soon as he starts working for a practice, clinic, hospital, clinic, or other healthcare facility.

Without approved medical credentialing, a medical practitioner is not allowed to see patients and if he does, he is not allowed to be reimbursed for the services performed.

What Are Medical Credentialing Requirements?

Credentialing requirements vary between states, cities, and even medical facilities and insurance carriers. To ensure that you meet all requirements, you should always check what information is required from each source.

Under the Affordable Care Act, medical practitioners are required to go through a longer credentialing process and meet more requirements so that fraud and abuse can be avoided. If the physician is starting work in a new medical facility, or he’s changing states, it’s always a good idea to look at the credentialing laws that might be different.

Any professional licenses, certifications, diplomas and professional references that the practitioner has are considered credentialing documents. The provider may be required to provide the following paperwork: 

  • Education and training
  • Hospital affiliation
  • State license(s)
  • DEA license
  • Provider enrollment application
  • Board certification
  • Malpractice insurance certificate
  • Sanctions disclosure
  • Criminal background disclosure
  • Military service

What Is the Importance of Medical Credentialing? 

Without proper credentialing of medical practitioners, many things could go wrong. It’s estimated that in the US alone, more than 250,000 people die from medical errors every year. If your employees don’t perform and monitor medical credentialing, you could potentially hire a physician without proper licensing and experience and put your patients at risk. This can further expose your hospital, physician office, dental practice, or surgery center to lawsuits and other legal repercussions.

Another problem is that without credentialing, your facility will have to face lost revenues. Insurance carriers do not offer reimbursement to any medical facilities that allow practitioners without proper credentials to bill for their services.

In case some of your medical practitioners are in the middle of the credentialing process but haven’t completed it yet, there is hope. Some insurers will backdate the reimbursement within a specific timeframe.

To avoid losing revenue, all the medical practitioners who you hire must have the proper credentials that are current and accurate.

Can You Simplify Medical Credentialing Info Gathering?

Before a medical practitioner can receive his credentials, he must provide an abundance of detailed information about his professional history. A single error could delay the already lengthy process, or even leave the practitioner without any credentials.

To eliminate the possibility of human error, outsourcing credentialing is a viable option. Credentialing Verification Organizations use web-based software to collect data, for verifications, reports, and more, and compile it all together to provide a detailed list of all the required information. This reduces costs, protects the healthcare institutions from financial harm, and at the end of the day, increases the patient’s safety.

Are There Medical Credentialing Courses Online? 

Since the whole process takes months to finish and providers must be revalidated by Medicare every three to five years, having credentialing staff take medical credentialing courses online can help your healthcare organization save time and money. Online medical credentialing training allows staff them to efficiently assess their knowledge, and learn to stay on top of everything they need to know to ensure medical staff credentials are kept up to date. 

Medical credentialing courses online allow medical credentialing staff including billers and practice managers to go through quick training sessions at their own convenience, without wasting any time. Many sessions are geared to the specific credentialing software such as CAQH or CAQH Proview for Practice Managers or using general software such as Excel to streamline the process. Many billing managers are able to save time after training on specific challenge areas including monitoring and recertification or hospital privileges including courtesy, admitting and surgical.

Improve the accuracy and timeliness of managing your provider’s hospital privileges with step-by-step tactics to help make the process faster and easier from credentialing and privileging expert, Brianna Foulkrod, CPCS, CPMSM. Sign up for the online training to learn more.

How Can You Ensure a Swift Credentialing Process? 

Besides applying for medical credentialing courses online, medical staff can do a few more things to expedite this whole process.

  1. Check and double check everything. As mentioned, a single mistake in the paperwork could delay everything and require you to resend all the information. The credentialing process is already lengthy, and any discrepancies and inconsistencies can cause problems.
  2. Contact your professional references beforehand. They should be able to respond quickly and accurately to verification requests, allowing you to speed up your credentialing.

Additional Medical Credentialing Courses

Medical credentialing is essential for medical billers and practice managers. Not only will you find it easier to get insurance reimbursements, you’ll be able to continue with your practice with as few hiccups as possible.

Reach out to us today to streamline your credentialing process! Here are some online credentialing courses that will help you streamline and monitor the credentialing process for your physician office, hospital, surgery center or dental practice.