Medical Credentialing

Power of attorney for health care is a very time-consuming process. It involves several complex steps that must be done in the right way or it could lead to huge financial losses. Not only that, other legal complications may arise that could threaten the entire healthcare organisation. Processes like registration, compliance, planning, and the like must be done with complete authenticity and clarity. However, healthcare practices are inclined to slow down the credentialing process due to a lack of knowledge or expertise.

What is Credentialing?

“Credentialing” is how practitioners become approved providers through a hospital, practice, or healthcare facility. It verifies the medical care provider’s qualifications. Such as their education, medical experience, licences, and more. In practice, this is done by completing and reviewing forms and verifying basic information. And following established payer standards for participation.

In healthcare, physician accreditation is the process of organising and verifying professional records that qualify physicians to practise medicine. This contains their board certifications, hospital admitting privileges, education, malpractice insurance, professional references, work history, etc.

Also Read:

• How to avoid credentialing related denials
• Recommendations for credentialing process flow

Some Credentialing Mistakes Lead to Revenue Loss

Here are;

Time is Everything in Credentialing:

Enough time to get payer approval so your new provider can get reimbursed. This estimated lead time is necessary to initiate the registration process to successfully obtain registration of a new provider with individual insurance and facilities.

Failure to allow sufficient time to gather the documentation needed to prepare. And process claims and insurance approval before the physician sees patients will result in providers not being able to bill patients for services provided.

Keep in mind that the approval response of individual payers is determined by their workload. Some payers, especially government payers such as Medicare and Medicaid, may take 3-6 months to process.

CAQH Lapse:

CAQH or Council for Affordable Quality Healthcare Inc. is a California non-profit organisation. That acts as an online repository for all physician-provided credentialing data. Insurance providers access this data through CAQH, so it is important to keep the data current. Your staff should take the time to retest profiles promptly to avoid data loss.

Accuracy and Completeness:

The Physician Credentialing process involves verifying a range of documentation, and certifications. And licences to assess medical qualifications, graduation, residency, residency, career history, and malpractice details. Processing a credential application is a tedious task that requires the utmost care to ensure the accuracy and completeness of the information provided. Because even an involuntary error or typo in the submitted details can lead to unwanted delays and rework of the entire authorization process. An inaccurate or incomplete application or documentation will affect the timeline. And revenue stream for the physician or medical practice.

Inaccurate Information:

Credential denials can come from inaccurate information in the form of inaccurate documentation. Errors in trivial details such as a doctor’s email address, and even missing data. These can be detrimental to the verification process because not all accurate information is available to assess the legitimacy of the physician. This will hinder the accreditation process during which the doctor cannot provide any services. And cannot be reimbursed for the services provided.

Failing to Take Peer Review Activity Seriously:

Information provided as part of a peer review or investigation should be taken seriously. And evaluated as part of the credentialing process. Peer references can shed light on a doctor’s skills. And competencies that you cannot obtain simply by verifying her education, training, or licensure status.

Although physician accreditation can be boring, the process protects healthcare facilities from risk and non-compliance. A thorough and ongoing medical examination is crucial to avoid costly malpractice. A hurried process leads to missing information, errors, and delays in reimbursement. As healthcare regulations develop and credentialing requirements become more complex. Healthcare facilities must be proactive in updating their credentialing processes to avoid mistakes that put patients and themselves at risk.

Lack of Expert Support:

Even remotely related to the healthcare industry, one would know that medical billing. And credentialing amenities are the elixirs that keep practices financially healthy. But unfortunately, in the last few years, insurance certification services have become more difficult, but not impossible.

A lot of things can go wrong if you try to do accreditation internally in your practice, so it might not be such a great idea after all. Forcing staff to deal with time-consuming and massive paperwork robs them of valuable patient care time. They lack the skills and experience necessary to meet process standards.

Errors in the Enrollment Process:

Billing and payments are very much tied to the registration process. As a result, any deficiencies in this area could have an impact on how healthcare revenue cycle management is addressed. Let’s take a look at some of the most common mistakes that occur during the registration process.

Each insurance company has its station of rules. And procedures for adding new providers to its console, including deadlines, procedures, and rules. Unfortunately, failure to meet provider requirements is a common mistake in medical accreditation.

Each insurance company has its own set of bases for adding new providers to its panel, including dates, procedures, and criteria. Failure to meet provider requirements is a common medical record error.

Before registration, insurance companies may have several questions, explanations, and verification of the primary source. If facility staff is not given the proper responsibilities to handle these inquiries for you, it hinders the payment process.

Insurance companies may have various questions, explanations, and primary source checks before registration. If facility staff is not given the necessary responsibility to handle these inquiries for you, the entire process may be delayed.

Failing to Report Adverse Actions:

Physicians are required to report adverse events, such as licence revocation; exclusion from third-party programs. And interruption or voluntary relinquishment of medical staff membership, clinical privileges, or state or federal DEA licence. Hospitals and health systems will be held liable for physician negligence. Therefore, due diligence requires a background check to identify current and historical adverse events.

Conclusion

To avoid all these errors and oversights, it is important that healthcare practices consider measures such as outsourcing, digitization, and hiring qualified resources. They should focus on expertise in managing the entire credentialing process. However, managing all clinical activities can be frustrating. Precatalytic could serve as your trusted partner. Our experienced professionals focus on providing the best possible accuracy of accreditations before they are sent to insurance companies.

If you plan to start your practice or bring new doctors into an existing practice. Your accreditation process must begin well in advance. It is important to understand how accreditation can significantly affect the speed of your cash flow. And how smoothly your practice runs. Ignoring the authorization process will result in delayed cash flow and difficult scheduling due to patient restrictions. Since accreditation issues can be expensive and reduce productivity. It is essential to have a process and plan in place to ensure accreditation remains current.

Recommendations for a Credentialing Process

Here are;

1. Appoint a Credentialing Coordinator:

Whether you outsource credentialing tasks or handle them in-house, appointing a credential coordinator to monitor deadlines and expirations is a wise business decision. They can send out timely reminders to ensure that no one’s credential expires. And refunds are not denied as a result.

2. Create a Sustainable Credentialing Process:

Creating a credentialing workflow can be testing, but it helps in the long run. Your workflow should maintain all required forms and documents, even if you outsource the authorization process. It seems that with a multi-physician practice always comes re-accreditation. And a workflow that accommodates it greatly benefits the practice.

3. Make Use of Advanced Software for Monitoring:

You don’t have to rely on administrative staff to manually monitor your compliance. The cloud-based billing software allows you to easily monitor the status of your credentials from anywhere, anytime. These platforms give you the ability to set up alerts to let you know if a task is about to expire or is due in your RCM cycle.

4. Outsource Medical Credentialing Services:

Medical accreditation can be a time-consuming process. Plus, small missteps in the process lead to frustrating problems later on. Therefore, working with a medical accreditation service provider like Prognosis can be one of the best tips you can follow. When you enter provider credentials using a service like Prognosis. A medical credentialing specialist will review the credentials in the provider registry. Within the organisation and ensure that everything is recorded as it should be.

5. Track Credentialing Applications:

Once authorization requests are sent to the insurance company or organisation, be sure to track the progress of that request. Feel free to contact the insurance company to find out where the application is in the acceptance process. It is not uncommon for payers to delay applications that lack information. Thereby delaying the timely notification of providers.

6. Provide Current Copies of Paper Documents:

For insurance companies that still require paper applications. Your credentialing specialist will need to submit hard copies of licences, DEA certificates, malpractice documents, and other documents, all of which must be current. If some documents are expired or contain incorrect information. This will delay the credentialing process as it takes time to receive and send updated versions of these materials. If some of these documents are submitted to the carriers. This will further delay the process as the insurance companies will then have to redo the new documents.

7. Identify Potential Risks:

• It is essential to identify potential risks early in the commissioning process.
• The applicant is not willing to provide all the required documentation.
• Clinical or coverage gaps.
• Sudden Termination of License or Privileges.
• Have short tenures in multiple organisations.
• An unusual number or history of malpractice investigations or lawsuits.
• Alcoholism/drugs/domestic violence/history.

If any of the warning elements are present in an applicant’s history. A follow-up interview may clarify the information or a more formal investigation may be required depending on the level of seriousness. Tell the candidate how you plan to proceed in both directions.

8. Stay All Physician Contact Information Up to Date:

The medical accreditation process usually involves various forms of submission. So clear communication throughout the process is very important. Without direct contact, credentialing or credential renewal issues can take longer to resolve than they should.

It’s equally important to ensure that your employees quickly update all important platforms. And channels within your process to correct incorrect or outdated information.

9. Require Peers References:

Our recommendation is to request three peer references from physicians in the same specialty. Who are not current members of the same practice or relatives? If you are going to set these standards for cross-references. Be sure to supply your specifications to applicants for this application.

10. Be Patient with the Credentialing Process:

Credentialing is a long and complex process with many components and steps. You should communicate regularly with your Accreditation Specialist about the progress of accreditation and re-accreditation of your physicians. Make sure you get regular updates and don’t hesitate to ask any questions.

Also Read:

• Expertise Avoid In Medical Credentialing
• Review Your Revenue Cycle Process

Why is Credentialing So Important?

Medical accreditation is increasingly important because it is the only procedure that allows patients to confidently place their trust in their chosen healthcare providers. RMB credentialing processes offer organisations efficiencies. Reducing the burden on all stakeholders and positively impacting quality. And in the process of verifying that a provider meets standards set by a state, employer, or insurance company.

Why Does It Takes So Long?

Once hired, health professionals cannot begin work at their new facility for several weeks to six months due to credentialing. On the provider side, the process only takes about three hours as they submit around 20 different credential forms. For facility staff, credentialing takes about 20 hours per provider as they perform several tasks that may include:

• Start a seriousness check.
• Collect and evidence credentials, clinical reputation, and case histories.
• Collect and review claims, privileges, and board history.
• Check penalties with the Office of Inspector General (OIG).
• Start by verifying primary sources such as the American Medical Association (AMA), medical boards, and educational history.
• Adjacent files to credentialing committees, executive committees, and facility stakeholders.
• Create a Bill of Rights and provide a letter of appointment.

Conclusion

Medical accreditation is undeniably important. It ensures that patients receive care from GPs with the correct credentials to give them the highest possible level of care. Therefore, payers undoubtedly make sure that care providers are properly qualified. They do this by following a strict system of checks to look for the correct credentials when submitting a medical application. Even with tips on best practices for medical accreditation, the accreditation process is complicated and time-consuming to navigate. Bringing in an expert with certification experience brings new efficiency to the process.

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The medical accreditation process (also known as physician accreditation or provider credentialing) is a tedious, resource-intensive, and time-consuming exercise. Like physical exercise, it’s not something you do once and then it’s done and dusted. It is a necessity in your medical practice, regardless of the size of your operations, that requires constant attention. Medical certification is required for physicians and nurses, physician assistants, and therapists. Essentially, anyone involved in patient care must go through a process of verifying their credentials.

Failing to Complete Recredentialing or Revalidation:

Health professionals must regularly renew their licences and credentials following the laws of the state in which they practise. Initial accreditation and re-accreditation every three years ensures. That healthcare practitioners are up-to-date on their certifications and licences. When hospitals fail to stay on top of re-accreditation. It can lead to doctors and facilities performing services. They are not certified or licensed to perform. This creates the potential for negative patient outcomes, which can lead to costly malpractice lawsuits.

Know Your Timelines and Plans Accordingly:

Unfortunately, confirmation from insurers has been reported to take up to six months. As mentioned earlier, some insurance companies require credentialing before contracts with the payer and payments are authorised. Knowing the exact details of how insurance companies release performance data goes a long way in planning future cash flows.

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Failure to Address Requirements for Updates:

Providers must regularly update their licences and other credentials as required by the state in which they practise. In addition, processes must be in place to capture transient changes in information such as phone numbers and other contact information. Processes that are systematic tracking required updates and people who are attentive to detail in managing these processes are critical to the success of a credentialing program.

Also Read:

• Medical Credentialing Processes
• 5 Things to know about medical credentialing

Submit Your Application:

Depending on the practice or network of insurance companies, it is necessary to submit a preliminary application. This filtering mechanism includes background checks to block medical personnel who do not qualify for medical certification. It focuses on criminal and disciplinary records, records of disciplinary proceedings, and board certificates.

After completing the pre-application process, you are now ready to submit all the required information. Again, you need to get it right on the first try to avoid lag. The longer the authorization process takes, the longer it will take to bill for your services.

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This is a doctor’s checklist that could help you tick all the boxes of the accreditation process.

• Educational history and transcripts.
• Current medical licence, DEA registration, and board certification.
• Work history.
• Proof of continuous malpractice coverage.
• Personal vaccination records.
• Personal medical history.
• Professional and personal references.
• Explanation of any gaps in work history.
• Hospital privilege or hospital affiliation
• Enrollment in CAQH
• Letters of recommendation
• Copy of CV.

Compliance Mistake:

Each state proposes different credentialing requirements, and failure to comply with these requirements could be one of the major healthcare credentialing issues. It can be caused by:

o   Ignorance of the Staff: When the staff at the clinic are tasked with doing the accreditation, complete ignorance on their part of the insurance provider’s requirements will screw things up. It takes an edified person to get it right.

o   Lack of Awareness of Legal Implications: Clinical staff responsible for carrying out credentialing work may not be aware of the legal implications of a given request. A layman’s ignorance of legal jargon is quite understandable, but if things go wrong, it can lead to legal risks for the device.

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Issues due to Lack of Digital Support:

Due to the extensive paperwork involved in credentialing, it is nearly impossible to keep the process organised if done manually.

o   Not Being Updated with the Process: The accreditation process by both state and private insurance companies is constantly being updated with new regulations. Keeping up with regular reviews is quite a burden if documents are still stored as hard copies.

o   Failing to Renew Licence and Credentials: In trying to keep up with a busy schedule, there is a good chance that clinic staff will forget to renew their credentials and licences. Certificates sometimes exceed their renewal date as part of the credentialing process, which, if not automated, can go unnoticed.

Poor Time Management:

The most common problem in the world of medical accreditation is simply poor time management. Many hospitals and other providers jump ahead in the hiring process—first hiring a provider, setting a start date, and then verifying credentials and registering a practitioner.

This also can avoid in Medical Credentialing Processes.

The safest and most convenient way to connect with a provider is to first verify their credentials. Then hire a person, and finally set a start date and sign up.

Most applications and credentials can take anywhere from four weeks to four months to complete. This includes recertification and relicensing. Which can seriously put a damper on a practising provider—and the income that person brings.

Lack of Credentialing Experts:

Physician credentialing, also known as medical or provider credentialing, is a tedious process that requires accuracy, attention to detail, and patience. All certifications and licence must be verified with each provider providing services to patients. Depending on the size of the group practice, verification of the employment history. And qualifications of all providers within the practice may be required. Each provider’s education, medical training, residency, and licences. And all board-issued certifications must be verified. Properly delegating each individual is a huge amount of work for the team. Generally, providers try to manage the verification process themselves or ask members of the billing team to take care of additional verification responsibilities.

Incomplete Provider Application:

The credentialing process can be daunting for providers as well. Applications can require a huge amount of information and incomplete information can cause the application to be rejected. Software and processes that validate complete applications can make the process faster and more efficient.

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Avoiding Common Provider Credentialing Mistakes

Although physician accreditation can be tedious, your practice must complete it for each provider as it protects the practice from risk and non-compliance. A thorough and ongoing medical examination is essential to avoid costly malpractice. A rushed process leads to missing information, errors, and delays in reimbursement. As healthcare regulations developed and credentialing requirements become more complex. Healthcare facilities must proactively update their credentialing processes to avoid errors that put patients and themselves at risk.

Conclusion

You know that the right credentials help your business run smoothly. But that’s not all your healthcare organisation wants to be as efficient and effective as possible.

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Because insurance companies require medical service and equipment providers to be credentialed before payment is made, the provider credentialing process goes hand-in-hand with payer contracts. Therefore, avoiding delays and streamlining the verification process is an integral part of the business as a whole. By removing the headache of credentialing and subsequent payer contracts, you can get back to what you do best: providing expert service and advice to your patients.