The healthcare quality management methodology relies heavily on credentialing and re-credentialing procedures. By participating in the provider network, those seeking and/or receiving care may be confident that their requirements will be met, thanks to stringent credentialing and re-credentialing procedures.
A continual evaluation process known as credentialing and re-credentialing is conducted to ensure that practitioners are up-to-date in their fields of expertise. This kind of evaluation ensures that practitioners have the necessary education, experience, credentials, and continuous competence to carry out their assigned tasks.
Different types of providers have additional requirements for first and subsequent re-credentialing. Before they may treat members, doctors, NPs, PAs, psychologists, and other medical professionals allowed to charge independently for their services must first get credentials.
Why It’s So Crucial to Maintain Credentials in the Healthcare Industry?
Some of the most compelling arguments may be found in favor of credentialing and re-credentialing in the healthcare industry, and they are:
Patient Security
It’s an essential step toward guaranteeing that doctors and nurses are adequately trained to treat their patients. This aids in minimizing the possibility of medical mistakes and guarantees that patients get safe, high-quality treatment.
Observance of the Law
Numerous authorities, such as state licensing boards, accrediting organizations, and insurance providers, demand it. Failure to meet these standards may result in legal action and financial penalties.
Integrity
This aids in fostering a culture of professionalism among medical staff. To keep abreast of developments and best practices in their industry, healthcare workers need to participate in continual education and training.
Credibility
Credentialing and re-credentialing in the healthcare industry are signs of a facility’s or organization’s dedication to maintaining high standards of care and protecting patients. Patients, medical personnel, and everyone involved benefit from this because it increases their faith in the healthcare system.
Upgraded Standards
Healthcare workers may enhance their knowledge and abilities by participating in credentialing and re-credentialing procedures. The results for the patient and the quality of treatment as a whole might increase.
When Does a Healthcare Professional Need to Renew Their Credentials?
Most states mandate initial provider credentialing and periodic re-credentialing. In certain states, providers must renew their credentials every three years.
Some health insurance policies may impose other conditions. Healthcare providers should verify all relevant statutes of limitations and policy requirements with their respective states and insurance providers.
Access to vital information for complete transparency on your providers, suppliers, support personnel, and businesses must allow you to better care for your patients.
How Do I Get Started with Re-credentialing?
At least 60 days before the re-credentialing deadline, a provider should be contacted so that the application process may begin. All applications should be made available to providers electronically.
The time it takes to be credentialed varies by state and organization, but it’s usually several weeks to a few months. Healthcare providers may save time by keeping all relevant documents on file and anticipating and preparing for any needs unique to their company.
What If a Provider Is Denied Credentials?
If a credentialing committee denies a practitioner’s re-credentialing application, the practitioner will get a notice explaining the committee’s reasoning and providing any supporting evidence. Medical professionals have the right to file an appeal.
Within 30 days of the refusal, the provider must submit a written request for reconsideration. All submissions must be made in writing and accompanied by necessary paperwork. The deadline for scheduling a reconsideration is 60 days from the date of receipt. If the supplier is refused a second time, they have no other options.
How to Maintain Credentialing Paperwork
Healthcare providers should keep records of the application for re-credentialing in the practitioner’s credentials file to avoid potential problems. In addition, they need to provide a mechanism to update the data as required.
Sybrid MD offers the most thorough data in the healthcare business to continuously check a provider’s credentials and licensing status. Its digital solutions for provider screening reduce administrative burdens while ensuring compliance with re-credentialing paperwork.
Sybrid MD’s persistent surveillance of a plethora of databases allows healthcare professionals to go about their business without fear of noncompliance. Providers and healthcare organizations may use top-tier technology to feel at ease throughout the re-credentialing process. This allows them to keep their attention where it belongs: on delivering excellent patient care.
Application for Renewal
It is necessary to submit a renewal application and payment to maintain your certification.
The following steps are typical for renewal application processing:
- When we receive your renewal application and payment, we’ll process it immediately and send you an order confirmation and order confirmation letter to verify your purchase.
- The next step is submitting your application to the Certification Division. The Certification Department will provide further information if your application is lacking any necessary supporting materials. If you have not heard back from the Department after six weeks, everything seems OK, and your application is progressing.
- Your application will be processed, and a new gold seal with your updated expiry date will be sent to you once it has been accepted.
Process Duration
Please be aware that depending on the current volume of applications, it may take anywhere from 4 weeks to 6 weeks to process a fully complete renewal application. Unnecessary status check emails and phone calls can slow our employees in processing all applications; therefore, please wait at least six weeks from the day your payment was received before contacting the Certification Department. If you have an immediate processing concern or deadline, please contact our office by phone or email.
What happens if it Arrives Late?
It might cost you both time and money, in addition to causing you more headaches. If you continue seeing patients after your contract with a particular insurance panel has ended, you risk being removed from that panel.
You might also forfeit reimbursements if the insurance panel denies your claims if you don’t revalidate your information on time.
What do you need to do?
To keep everything orderly, you must maintain an eagle’s watch on following.
Re-attest CAQH profile every three months
Physicians dealing with 3rd party insurance panels must certify or revalidate their information every 120 days. If you update your CAQH profile on time, your billed claims may be allowed.
Update the CAQH profile on each demographic update.
If there is a change in any of the provider’s demographics, it has to be changed in the CAQH profile. As CAQH includes a broad range of information, it’s challenging to maintain if you don’t evaluate and update it frequently.
Re-Negotiating the Contract
The contract period between doctors or healthcare providers and third party insurance panels is generally two years. After term period, you need to re-contract in order to secure your credentialing or enrolment with the insurance panel. The re-contracting also gives a chance to negotiate service pricing or other terms.
How do you finish the Re-credentialing Process?
Once you get notice for re-credentialing, the primary objective of the notification is to guarantee that your professional credentials remain valid and current. The notice will take you towards the next important step according to your speciality.
For Medical Providers
If you have an updated profile on CAQH, you may not need to take any action when re-credentialing.
If you wish to edit any information, log on to CAQH and update your information.
Once you have submitted your modifications, you need to validate that all the information is accurate and current.
For Medical Facilities & Hospitals
You will have to complete the re-credentialing application form and email the same to insurance panel.
Read the recommendations carefully in the notice obtained from the particular insurance network. You may also visit their website to locate the particular form. Just complete the form
It might take up to 5 business days to complete your re-credentialing procedure after you submit all the needed supporting papers and the same have been received by insurance payer.
How to verify status of Re-credentialing Application?
You may verify the progress of your credentialing application by making an email request to appropriate insurance panel at their supplied email address.
The email address may be retrieved the website of the insurance panel.