Credentialing Corner

How Provider Credentialing Works in Healthcare? An Informative Guide

The goal of provider credentialing is to ensure that healthcare providers meet certain education, training, and experience standards before being allowed to provide medical services to patients.

But how provider credentialing works? The credentialing process typically involves verifying a provider’s education, training, licensure, certification, work experience, and any other relevant credentials. This process may also include conducting background checks to ensure that the provider has no history of malpractice or other disciplinary actions.

Credentialing is naturally performed by healthcare organizations such as hospitals, clinics, and insurance companies to ensure that they are working with qualified providers. It is also important for providers to maintain their credentials by keeping their licenses and certifications up-to-date and meeting continuing education requirements. Let’s explore the process more deeply and understand why credentialing is important for medical billing.

Primary phases of provider credentialing

Primary phases of provider credentialing
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The primary phases of provider credentialing include three important steps;

  1. Gather information;

The first phase of provider credentialing involves gathering information about the provider’s background, license, education, and other credentials. Some healthcare facilities ask the provider to provide the credentials through email, and some ask to fill in the information in the provided form. 

Often, healthcare facilities and insurance companies hire credentialing verification organizations (CVOs) to gather and verify provider information. The process of verification through CVOs is more efficient and quick.

  • Checking information

Many times healthcare facilities and organizations perform background checks. They contact medical schools and licensing agencies to verify the authenticity of the provided information from the provider.

On the other hand, facilities and agencies often use software available online to check the information regularly to see if the certification and the license are updated and not expired. This is also done through CVOs.

3 – Awarding credentialing

After facilities or insurance companies verify the authenticity of the information, they provide award credentials to the provider. Insurance companies allow the provider to work as an in-network provider. This means that the insurance companies will reimburse the providers for treating patients who have their insurance.

How does medical credentialing work?

How does medical credentialing work?
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Medical credentialing verifies and evaluates the qualifications, licenses, and other credentials of healthcare providers. Medical credentialing ensures that healthcare providers meet certain standards of education, training, and experience before they are allowed to provide medical services to patients.

The medical credentialing process typically involves the following steps:

Submitting application

The healthcare provider submits an application to a healthcare organization or insurance company, providing information about their education, training, licensure, certification, work experience, and other relevant credentials.

Verification of the credentials

The credentialing organization verifies the provider’s credentials by contacting the issuing authorities, such as educational institutions, licensing boards, and certification organizations. This phase also includes verifying the provider’s work history, malpractice history, and any other relevant information.

Reviewing application

A credentialing committee or individuals at a facility or the concerned authorities evaluate the provider’s application and verifies information to determine whether the provider meets the organization’s credentialing standards.

Approval or denial of the submitted application

The credentialing organization either approves or denies the provider’s application based on the results of the verification and review phases. If approved, the provider is granted privileges to provide medical services to patients within the organization or network.

Ongoing monitoring

Once approved, the credentialing organization monitors the provider’s credentials on an ongoing basis to ensure they remain in good standing. This includes periodic re-credentialing, which involves repeating the verification and review phases at regular intervals to ensure that the provider continues to meet the organization’s standards.

Why do medical billing companies promote credentialing?

Why do medical billing companies promote credentialing?
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Medical billing companies promote credentialing because it is an important part of the revenue cycle management process. Credentialing ensures that healthcare providers are properly qualified to provide medical services and are authorized to bill insurance companies for those services. Here are some reasons why medical billing companies promote credentialing:

  • Increased Reimbursements: Healthcare providers can bill insurance companies for their services and receive reimbursements at the appropriate rate when they are properly credentialed. Credentialing helps ensure that providers are authorized to bill insurance companies for their services, which can help increase the revenue they receive.
  • Reduced Denials: When healthcare providers are not properly credentialed, insurance companies may deny their claims for reimbursement. This can result in lost revenue and increased administrative costs. By promoting credentialing, medical billing companies can help reduce claim denials and ensure that providers receive their entitled reimbursements.
  • Compliance: Credentialing is an important part of regulatory compliance for healthcare providers. Medical billing companies that promote credentialing help ensure that their clients are in compliance with regulatory requirements, such as those set forth by the Centers for Medicare and Medicaid Services (CMS) and other governing bodies.
  • Improved patient care: Credentialing helps ensure that healthcare providers are properly qualified to provide medical services, which can help improve patient care. Medical billing companies that promote credentialing help ensure that patients receive care from qualified providers, which can result in better health outcomes and patient satisfaction.

Promoting credentialing is an important part of medical billing companies’ efforts to help healthcare providers manage their revenue cycle and ensure regulatory compliance.

Entities that regulate credentialing of providers

Entities that regulate credentialing of providers
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There are several entities that regulate credentialing of healthcare providers. These entities are responsible for setting standards and guidelines for credentialing and overseeing the credentialing process. Some of the key entities that regulate credentialing of providers include:

The Centers for Medicare and Medicaid Services (CMS):

CMS sets standards for credentialing and re-credentialing healthcare providers participating in Medicare and Medicaid programs. This includes provider qualifications, licensure, certification, and work history requirements.

The National Committee for Quality Assurance (NCQA):

NCQA is a nonprofit organization that develops and maintains standards for healthcare provider credentialing. NCQA accreditation is a widely recognized credentialing standard in the healthcare industry.

The Joint Commission

The Joint Commission is an independent, nonprofit organization that certifies healthcare organizations and programs in the United States. The Joint Commission sets standards for credentialing and privileging of healthcare providers within accredited organizations.

State Medical Boards

State medical boards are responsible for licensing and regulating physicians within their respective states. They set standards for physician licensure, education, training, and practice and oversee the credentialing and re-credentialing of physicians within their jurisdictions.

Professional Certification Boards

Professional certification boards are responsible for certifying healthcare providers in specific areas of practice, such as nursing, pharmacy, and allied health professions. They set standards for certification, including education, training, and work experience requirements, and oversee the credentialing and re-credentialing of certified providers.

These entities play a critical role in ensuring that healthcare providers are properly qualified and authorized to provide medical services to patients. They help establish and maintain standards for credentialing that promote high-quality care and Patient safety.

Conclusion

Medical credentialing is an essential process that enables providers to receive compensation for the services they provide. The process is typically performed by healthcare organizations such as hospitals, clinics, and insurance companies to ensure that they are working with qualified providers. It is also important for providers to maintain their credentials by keeping their licenses and certifications up-to-date and meeting continuing education requirements.