Does even thinking about new provider credentialing give you a headache? Sure, you’re anxious for new providers to start generating revenue for your practice. But you’re also dreading those long, complicated forms that are so easy to mess up.

Credentialing is anything but simple. One misstep, and your practice’s revenue cycle will slow to a halt. Whether you’ve waited until the last minute or just don’t have a well-defined process to follow, it’s not uncommon for problems to pop up during the new provider credentialing process. Not only that, but the requirements of health plans and hospitals are constantly changing.

If you don’t know where to begin when managing new provider credentialing, you’re far from alone. Luckily, there are ways to minimize many common new provider credentialing issues. Keep reading for answers to the most-asked questions that will jump-start your new provider credentialing process.

Is There a Difference between Provider Credentialing and Enrollment?

Yes, these terms are often used interchangeably, but there’s an important difference:

• Provider enrollment is the process by which a provider is approved to seek reimbursement from payers (Medicare, Medicaid, and private payers) or seek admitting privileges at a hospital.
• Provider credentialing goes a step further. Credentialing is the process of obtaining, verifying, and assessing a provider’s qualifications to provide patient care.

Think of it this way: Enrollment is like a resume. Credentialing is the interview. If a provider passes both, they’re “hired.”

In What Order Should I Enroll and Credential My Provider in the Health Plans?

When determining in what order to tackle health plan credentialing, the main thing to consider is if the health plan will allow you to retroactively bill for services the provider rendered while not credentialed. The plans that will not allow you to bill retroactively are the plans that you want to enroll in first.

What Is a Key Thing I Should Know to Ensure Providers Are Credentialed Quickly?

Make sure you include ALL the information the application asks for the FIRST time. Incomplete applications can really slow down your credentialing process. Unfortunately, it can be tough to track down everything you need from a busy new provider. Here are some tips:

• Before you start provider credentialing, create a communication plan between you, the provider, and anyone else involved in the process. Communicate to everyone from the beginning exactly what information you need, why it’s important, and any related timelines or deadlines. The more information you can provide to them, the higher the likelihood of you getting back the information you need in a timely manner.
• Thoroughly review all applications before submitting them to health plans or hospitals. Everything must be legible and filled out according to the particular standards of the health plan/hospital. For example, if you’re filling out Medicare forms 855I and/or 855R by hand, there’s a requirement as to the color ink you can use.
• Don’t just assume that the application is complete after the provider has added their information. This includes any additional documents you need besides the application—make sure all the necessary attachments are included. If you do have a resume or a CV to go along with the application, compare that with the information on the application and make sure there are no discrepancies.
• Ensure all signatures are present and dated, and that they’re original (not stamped) when required.

The Hospital Is Asking Our Provider for References. Who Should We Ask?

Hospitals typically ask for three references when credentialing providers. But not just any references will do — there are guidelines around what those references should be. They should include:

• • Someone who has personal knowledge of the provider’s current clinical skills, who has observed them in action, and can speak to the provider’s ability to work cooperatively with others.

• A professional peer reference from someone in the same specialty.
• Someone who has been recently responsible for the providers practice at a healthcare organization (for example the department chair or chief of staff).

Make sure that all provider credentialing references are specific in nature. If they are too vague, the hospital may consider the application incomplete.

Should We Be Concerned About a Provider Who Has an Irregular Record?

It depends. There are several red flags that will put a provider’s application under extra scrutiny and slow down the credentialing process. For example, if a provider has a foreign education, it may take extra time to verify as opposed to a U.S. education. These red flags are similar to things that would stand out on anyone’s resume:

• Gaps in practice or training programs
• Change in staff category
• Instances of discipline
• Frequent moves (job hopping)
• Voluntary resignation under threat of discipline
• Cancellation of liability insurance
• Malpractice claims

Any circumstances related to the above list must be thoroughly explained in the provider credentialing application. If any of these situations apply to your provider, it’s a good idea to give your organization a heads up so that they know to expect possible delays in application processing or even a risk of non-approval. Keep in mind that if one health plan has notified you that there is a difficulty or a discrepancy, know that the other plans are likely to come back with that same issue.

The Provider Credentialing Process Is Really Overwhelming. How Can I Stay Organized?

There are so many moving parts to the new provider credentialing process that it’s all too easy to get thrown off track and miss a deadline. Luckily, there are several things you can do to minimize the chances that something will fall through the cracks:

• Create a detailed checklist for the credentialing process. Include a system that allows you to track where an application is in the process and identify upcoming due dates. This can be something as simple as a document that lists each task, the date when completed, and includes space for any comments.
• There are software programs you may consider. There are a lot of them on the market and that market seems to be growing and changing quickly. Before you spend money on a software solution, be sure to do a cost/benefit analysis. You should also talk with organizations of a similar size or need to determine if they have a solution they are happy with. When comparing the cost of systems, be sure you’re comparing apples to apples.
• Don’t forget — even a simple Excel spreadsheet or Word document can work wonders! You can even stay on paper. If you have a good system on paper that is comfortable for you, just keep using it.

How Should Our Practice Reorganize Our Credentialing Process?

Because the credentialing process has so many details and moving parts, there are several areas where the process could get off track. When creating a new provider credentialing process, try to find solutions to the following three big barriers to timely, successful credentialing:

• The credentialing process, requirements, and timeframes are always subject to change. What you might be doing right today could be wrong tomorrow. Implement a system for tracking and adapting to regulatory changes.
• In general, healthcare has a higher staff turnover than other industries. The constant coming and going of employees can make the credentialing process difficult to keep track of. Specific protocols, including a checklist and/or flow chart, ensure that a new employee can pick up right where a previous employee left off.
• Support for an organized, functional credentialing process must come from the top down. A lack of support or knowledge by leaders in your organization can make it difficult to get everyone on board.

How Can I Keep Up to Speed on New Developments and Changes in the Credentialing Process?

The parameters of provider credentialing will continue to grow as regulations change. There are several resources that can help you stay up to date on the constantly changing world of credentialing:

• Payer sites (including cms.gov) and payer newsletters. For example, CMS will often alert to upcoming changes a year ahead of time.
• Peer groups and professional associations like the National Association of Medical Staff Services (www.namss.org).
• Staying connected is critical. One of your best bets is to contact your health plans and hospitals and find out who you can contact about provider credentialing questions. Use that information to put together your own contact list that’s available to your practice staff.

We Are Closing a Practice Location. Do We Need to Terminate Our Enrollment with Our Health Plans?

Yes. Just because you’re not billing those plans anymore doesn’t mean someone else couldn’t. You definitely don’t want a bad actor getting ahold of your information and using it to fraudulently bill under an entity that no longer exists.