Physician Credentialing Services

A large number of organizations offer medical credentialing services to physicians with varying levels of medical credentialing knowledge. The credentialing process has been described in different terms by various individuals and groups over the years, including Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Point of Service (POS). Because the credentialing process varies by type of program, it is necessary for the organizations to understand the benefits of their credentialing process and why they need to get enrolled. This short guide provides an overview of the entire credentialing process, including some of the key benefits to organizations that choose to implement their own medical credentialing service. With this information, you can determine whether you need a credentialing process and what type of service would be best suited for your organization.

Doctor Credentialing Process

The healthcare provider, the organization, and the payer all need to be involved in the medical provider credentialing process.

The credentialing application is usually provided by the organization to the healthcare professional (s). He or she is in charge of filling out the application – which could be hundreds of pages long – and attaching any required evidence, such as board certification, college degrees, and other credentials. The provider sends the application to the organization to which he or she intends to deliver services once it is completed.

Additional evidence, such as claims history, background screen findings, primary source verification, and more, is then attached by the organization.
They submit the completed application and supporting documents to the payer after completing any healthcare facility components of the application and attaching necessary documentation.

The payer examines the application to see if the healthcare provider complies with the payer’s requirements. The provider’s education (and accreditation of that school), residency or fellowship, referrals, malpractice claims history, licensure, and other factors will all be taken into account.

This entire process is required when a physician first starts a new practice and then every two to three years after that, depending on the payer.

Documents Required

• National provider identification (NPI)

• Practitioner License(s)

• Malpractice Insurance (Certificate of Insurance)

• Board Certification(s)

• Updated CV

• Current driver’s license

The credentials system is comprehensive and thorough. It covers all aspects of healthcare and associated services in order to keep standards high.

Can a provider work during credentialing process?

No. A healthcare provider needs to wait until the credentials are comprehensive and authorized before they can start working. This ensures that each patient is always cared for by specialists who have the right education, experience and training in order to diagnose and deal with their health concerns. By allowing non-credential persons to work, even if they are getting their credentials, an institution becomes legally vulnerable and jeopardizes the loss of its institutional credentials.

Medical students, inhabitants and fellow members do not need a credential until their work goes beyond their programe of training. They are, however, guided and monitored by qualified professionals. They have not completed their training yet and are therefore not eligible for credentials and privileges, so that they can get an experience that offers a product their qualifications and privileges later on.

Credentialing committee

By monitoring the application evaluation and ensuring that all parties meet the appropriate standards, a credentials committee maintains the integrity of the process. Typically, a committee includes doctors with various medical specialties, a chairman and a liaison with CVO. Everyone else may also end up serving on the board.

In the some of the cases, you may file an appeal to the committee. This is not the situation if you do not satisfy basic credentials. If you have the right to appeal, you will obtain information about how to do it if necessary.

Privileges

During the application process, the CVO will obtain the following information for privileging, and the credential committee will decide on that basis. Typically, a supplier must complete a form to request privileges in two varieties.

Main privileges are regularly scheduled privileges shared by medical professionals based on what they have learned in specialty residency programs. Specialty privileges are routine privileges requiring additional training. To assess the ownership of specialty privileges, a CVO requires additional documents.

Doctors in each area contribute to the development and determination of privilege forms.

Cost of credentialing services

Medical credentials range from one specialty to another, from one establishment to another and from the CVO to the CVO. Typically, a $2-300 application fee is not out of the ordinary. Facilities often offer reimbursement or partial reimbursement once credentialing is successfully completed.

Just after initial credentialing, periodic reviews are required, and CVOs normally provide this at a reduced rate.

Do I need to update my credentials?

Hospitals and clinics regularly reassess the credentials of a provider, usually once each 1 to 3 years. This helps keep healthcare workers highly skilled if a provider fails to comply, its privileges expire, and patients can no longer be seen at the facility. For reinstatement, the application process must be completed again.

The choice of a credential service could depend on the hospital or clinic to which you apply. If you represent a health care facility or are an optional provider, the usual rules should apply here as elsewhere. Look for a good reputation and experience. Some services are at the forefront of the industry, while others have lagged behind. Here are five of the industry’s best service providers.

Benefits of credentialing services

Implementing your own medical credentialing program
One of the first benefits to implementing your own medical credentialing program is that you can control its cost. In most cases, organizations pay third party organizations to perform this task. For HMOs and PPOs, this third party service usually charges the organization a fee per service, with an overall cost determined by the type of program and the provider network selected. With a POS program, the organization must perform the enrollment process, which may include contacting multiple vendors to request information or conduct demographic studies on eligible patients. Some vendors charge a flat fee per service, while others charge a subscription fee based on the number of services performed.

credentialing process eliminates duplication

Another benefit is that the credentialing process eliminates duplication of services provided by other healthcare organizations. When you select a vendor to perform this service, you reduce the potential for providers to offer the same or similar services to other patients. The quality and results achieved through the vendor’s work are also likely to be consistent with those of other institutions. If not, the cost of offering these additional services would likely be higher than they would be under your circumstances. Again, quality of care is one of the most important benefits to implementing this process.

save money

You can also save money through the medical credentialing process. By requiring a provider to meet the same rigorous standards as other hospitals and healthcare organizations, the premium associated with healthcare services will likely be lower. Premium costs for many types of services are quite high for uninsured patients, even when they have established medical problems. By requiring the same high standards of care for all patients, insurance carriers will also be provided with a list of hospitals that meet the lowest standards, giving them an opportunity to provide cheaper rates to insured individuals.

save time
You may also save time through the medical credentialing services. Most organizations that perform enrollment in Medicare require applicants to meet a number of specific pre-requisites. Depending on whether you are a Medicare Supplement or Parts A and B coverage member, you may be required to complete an enrollment packet that contains specific information about your medical history, medications, educational history, current medical condition and details about your employer. This packet, along with supplemental information about your family, completed demographic information about you, healthcare provider credentialing information, employment history, etc., may need to be submitted on or before the first day of the month. If you are able to enroll in Medicare early, you may be able to avoid the submission of this important packet.

If you decide to use a non-medical professional to perform the enrollment process, it is important to know whether their experience and expertise will be adequate to ensure the accuracy and integrity of the data you are requesting. Some companies rely upon paper enrollment sheets and manual data entry. While these methods may be effective in some situations, if they are used incorrectly they can result in inaccurate data, which can negatively impact benefits or premiums. Having a professional medical personnel perform the enrollment process ensures the highest level of accuracy and integrity.

• Medical credentials provide the medical industry with quality assurance which benefits all concerned. Hospitals can be confident that perhaps the personnel they recruit will provide care in accordance with their required standards. Insurance providers have an incentive to maintain their costs, and therefore prefer to guarantee only those experts who are competent enough to practise medicine.

• Practitioners benefit from health credentials because they can increase the number of sick people who have access to them once they have the privilege to accept customers of the insurance companies. Finally, patients may benefit greatly, knowing that the medical industry maintains strict procedures to ensure that the health care provided to patients is of utmost quality.

• The benefits of medical credentialing include maintaining confidence in the ability of medical professions, minimizing medical errors and reducing costs. This system ensures that everyone gets better.

Get Credentialing Services from experts

There are a number of benefits associated with using an expert medical professional for provider enrollment. The primary benefit is that an experienced and licensed professional will have indepth knowledge of Medicare and Medigap policy rules and procedures, as well as the medical history of the individuals under their care. This information will help ensure that your enrollment is completed accurately and timely, resulting in fewer mistakes and missed opportunities. In addition, using an authorized provider can help reduce the potential for fraud by ensuring that healthcare providers follow accurate documentation rules and laws.

FAQ's

What steps must be taken to complete credentialing?

(1) You must complete the application completely. If you do not complete the application entirely or if additional information is required, a representative from the House of Outsourcing will contact you. It is critical that you respond to those requests as soon as possible, or we will be unable to process your application. (2) House of Outsourcing cross-checks specific data points with the “primary source.” That includes the state licensing board, your professional training/education, and so on. (3) Once the source verification is complete, your application is presented to a committee of your peers, who will decide whether or not you meet our requirements. (4) If your application is approved, you will end up receiving a welcome packet and guidelines in the mail.

How long will it take for my application to be processed?

House Of Outsourcing aims to complete credentialing applications in 60 days or less. This could take longer if you submit an incomplete application or do not include requested attachments with your application.

How frequently do providers need to be re-credentialed?

Providers must renew their credentialing every three years, beginning with the date of their initial credentialing (unless their state has other requirements). To remain a participating provider, a provider must successfully pass re-credentialing.

What happens during the re-credentialing process?

After about two and a half years in the network, you will be notified for re-credentialing. Your specialty-specific instructions will be included in the notification. You may not even need to take any action at the time of re-credentialing if your application is on CAQH and is kept up to date.

What if the Credentialing Committee rejects either my initial participation application or my re-credentialing application?

Depending on the reasons for the committee’s decision, you may be given the option to provide additional information and file an appeal. Your denial or termination letter will explain your rights as well as the timelines you must adhere to.

Can I submit a state application in the state where I practice?

True. House Of Outsourcing follows all of the state-mandated application guidelines.

What exactly is a National Provider Identification Number (NPI), and where can I get one?

NPI stands for National Provider Identification (NPI). If you are unsure how to obtain an NPI, you should contact your state licensing board to learn more.

Is it necessary for me to have a Medicare number in order to participate with House Of Outsourcing Care Solutions, LLC.?

If you are going to provide services to Medicare members, you must have a Medicare number. House Of Outsourcing prefers that you have one so that you can participate in all health insurance plans. Some health plans require you to have this number in order to use any of their products.

What exactly is a CV, and is it required?

CV stands for curriculum vitae. It’s similar to a resume in that it includes a summary of your educational background, work history, professional license, and any other special training you’ve received. You are not required to submit a CV to the House of Outsourcing. Instead, fill out the application questions.