Do you agree that healthcare professionals are responsible for provider credentialing process? How important is this for healthcare professionals to run their practice? Few questions are very critical to answer. The fact is that the Provider Credentialing services are very often delivered by healthcare professionals or providers. It’s known to be a step by step process of gaining network with insurance payers.

When there’s a question if healthcare professionals should choose provider credentialing process or the provider contract, the best suggestion would be to go for Provider Credentialing initially to stay in network. Every healthcare provider will have to undergo credentialing process to stay connected and skip going out of network.

What is Provider Credentialing Process?

  • Provider credentialing process basically refers to verification of professional skills, education and training of healthcare professionals which is followed by cross checking with the primary source that has provided license, training and education.
  • The Provider credentialing process is mostly preferred to hire healthcare professionals or facilities and assess the insurance company’s quality to participate in network.
  • To ensure proper credentialing process, it’s better to understand the differences between provider credentialing and enrollment.

Why do healthcare professionals need Provider Credentialing?

  • It’s evident that provider credentialing with insurance companies enables them to choose patients with certain and specific medical insurance plans and check if they can bill for the services rendered without any difficulties.
  • Eventually, it helps in expanding the patient base and also doesn’t interrupt revenue payments.

How do Healthcare professionals get to choose their panels?

  • Usually, the panel selection depends on credentialing process. As soon as healthcare professionals undergo credentialing process, they get to choose their preferred insurance panels to work with.
  • Each credentialing company will have a specific process that fits to their plans and procedures which can often be hectic.

When do healthcare professionals complete their credentialing process?

  • Generally, provider credentialing process depends on the healthcare professionals and takes approximately 90-120 days.
  • If the required applications are submitted according to the panel policies without any mistakes, the time taken is shorter than expected.
  • Regular follow up with the insurance companies will ensure if the applications are processed and approved within specified timings.

How are Providers guaranteed to get on the panels they choose?

  • When the healthcare professionals are fully licensed, they should most probably not have problem in identifying insurance panels to get credentialing done.
  • Certain insurance panels can be selective. In those circumstances credentialing companies will approach healthcare professionals and clarify their doubts regarding the credentialing process. It will help them to maximize their reimbursements.

When can providers re-credential their services?

  • It is advisable that healthcare professionals get re-credentialing done once in two or three years.
  • Sometimes it is required to be done more often as few insurance companies or healthcare facilities and organizations want to get frequently re-credentialed. But it completely depends on the panel and provider requirements.

What’s the purpose of Credentialing Verification Organization?

  • CVO refers to Credentialing Verification Organization accreditation to make sure if the credentialing process is performed meaningfully, strictly and also equally which benefits both the patient as well as the provider.
  • This particular Credentialing Verification Organization prevents healthcare professionals with poor credentialing practices and fraudulent activities to serve the patients.

What is the difference between Provider Credentialing and Provider Enrollment?

  • Provider Enrollment is a process that focuses on medical provider’s enrollment and arranging them into proper insurance plans, network, Medicaid and Medicare so the revenue payments are guaranteed for the services rendered to the patients.
  • The healthcare professionals those who choose to be enrolled with major insurance plans are preferred and considered as “in network”.
  • It’s a better choice for patients as they are able to receive more cost saving services compared to healthcare professionals who are out of network.
  • Provider Credentialing process refers to the gaining network of healthcare professionals through step by step procedure, to be connected with major insurance companies.
  • Provider credentialing services are most often delivered by hospitals, healthcare professionals as well as organizations.

Whom should Providers contact to know their Credentialing status?

  • Most of the provider credentialing services replies to emails regarding the status of credentialing process.
  • Some credentialing services will send regular updates and notifications regarding credentialing status prior to the questions from healthcare professionals to ensure minimal delay in any required action.

Will differences between individual credentialing and group credentialing impact the practitioner?

  • Individual credentialing refers to medical practitioners or healthcare professionals who require credentialing services without any group participation.
  • Group credentialing refers to healthcare professionals who require credentialing services involved in a specific group.
  • Group credentialing services is considered to be more flexible as it does not interrupt the facility provided to the healthcare provider even after leaving the group.

Are healthcare professionals allowed to work without proper credentialing?

  • Absolutely not! Apart from medical student or trainer, healthcare professionals aren’t allowed to work without completing the credentialing process.
  • Provider credentialing is a must for the provider’s practice so that they don’t fall out of network and lose their payments.

What does the application contain? How important is accurate information?

  • The application must be filled with the complete details of the healthcare professionals which includes the license, provider ID, complete address, NPI number and email address.
  • All the information must be fully completed without any gaps and accurate details are required for the credentialing process to be completed smoothly. Otherwise it would consume more time of the staff to recheck the information and rectify it as needed.

Hope you got the information on FAQs of Provider Credentialing. For suggestions, shoot your questions below and we will try to answer if relevant to the topic. For more queries and updates on healthcare, please subscribe to our blog.