AWhat is Physician Credentialing?
Physician credentialing in the healthcare industry, is the process of gathering and confirming a doctor’s professional credentials. Board certifications, hospital admitting privileges, schooling, malpractice insurance, expert references, job history, and other credentials are all included in physician credentialing services. It serves as an essential precaution for risk management and patient safety. So, the education, training, credentials, and licensure of practitioners needs the verification by primary sources, and organizations have to keep a dossier on each provider.
How to Credential a Physician?
A doctor authorizes an organization and/or its credentialing personnel to investigate their background, education, licensure, and professional qualifications when they apply for admitting privileges in a hospital or medical practice. A doctor must have the appropriate credentials for the procedures and specialized tools they will utilize in their field of practice.
Physician credentialing should be done by organizations so they can verify the accuracy of the information the doctor submitted with their application. The practice, hospital or credentialing personnel will carry out primary source verification for some provider data. As it necessitates getting in touch with the organizations or boards that granted the initial certification. For instance, a medical billing company could get in touch with the doctor’s medical school to confirm that he or she did really attend and earn the claimed medical degree.
Here are the key tasks that each doctor is normally have to finish during the credentialing process, even though the stages can vary depending on the organization:
Application (online or paper):
Doctors typically need to fill out a separate application for each facility they plan to work at because each one has its own requirements. So, these can be anywhere between 10 and more than 100 pages long in rare circumstances.
Supporting documents:
The information on this includes your medical licenses, Drug Enforcement Administration (DEA) ID number, malpractice insurance company, and case information, board certification, educational background, employment history, and health records. Additionally, many institutions want activity or procedure logs.
Verifications:
The medical staff services office will start confirming your malpractice carriers, job history, education, and peer references as soon as you submit your application and accompanying paperwork. They do this by contacting the relevant businesses or people directly.
Approval:
Mostly, department heads and hospital boards meet to go over the application and any supporting paperwork and to approve the hiring of the doctor. Some facilities just need the approval of the medical staff services office. This stage of the process could take up to a month or longer, depending on meetings .
Re-credentialing (if necessary):
Some facilities only provide privileges during the physician’s shifts (for example, three months on a locum tenens assignment). Other hospitals offer permanent and locum physicians certification for the full two years. So, tkeep you’re credentialing and hospital privileges, you might need to reapply and submit more evidence at some point.
Requirements for Physician Credentialing
In an effort to combat fraud and abuse, the Affordable Care Act significantly enhanced the physician credentialing standards for Medicare and Medicaid enrollment. Currently, the federal government, each state government, and each certification organization demand that physicians have credentials.
The credentialing procedure for physicians should be started as soon as feasible because it can take between 90 and 180 days. Each payer has an own internal schedule for processing applications. Hence, the scale of some payer organizations can make it impossible to expedite an application..
Practice Documentation Checklist
- CP575 OR 147C Letter
- Signed and completed W9 form
- Business License
- (If required in your state) Fictitious name permit
- Articles of incorporation or organization
- Liability insurance coverage
- Worker’s compensation insurance coverage
- CLIA certification or waiver
- EFT verification from your bank or a voided check
Provider Documentation Checklist
- Professional license
- DEA certification
- CDS certification
- Board certification or proof of eligibility
- PLI certification
- Professional school diploma
- Certification of completion for internships, fellowships, or residencies
- CAQH login and password
- PECOS login and password
- State Medicaid login and password
- Availability system login, password, and backup codes
- Current CV with exact beginning and ending dates
- Hospital admitting privileges or covering provider
The Challenges of Physician Credentialing
The medical credentialing procedure has a wide range of potential problems and outcomes. In fact, one of the most significant compliance challenges in a medical practice is provider credentialing. Omissions or mistakes that happen in the medical credentialing process can be harmful to your company if there is no process supervision and no data insight.
Errors can occur during any process. However, errors in credentialing may ultimately result in the loss of a person’s license or the reputation of your company. As you are aware, in the healthcare industry, missing credentials or compromised privacy carries a lot of weight. Additionally, to enrollment problems, a badly managed credentialing system may also result in legal and financial difficulties.
Applications for medical credentialing frequently contain information that is either obsolete, missing, or incomplete, which can create lengthy delays in the credentialing process. The job history, present employment status, malpractice insurance, hospital privileges, and attestations are the information.
The consistent credentialing program of The Coalition for Affordable Quality Healthcare has been adopted by the majority of payers in the United States (CAQH). Therefore, physicians who maintain their information with CAQH are credentialed and re-credentialed with fewer delays.
Physicians should be aware of and abide by the accreditation rules in their state. The laws are distinct in each state. Many states have reciprocity laws, which means that if a doctor gets credentialed by a payer in one state, being credentialed by that same payer in another state can be simplified. A doctor switching practices within the same state would not need to go through the entire credentialing procedure once more.
For a doctor working at another location, hospital credentialing is no longer valid. This was normal in the past, but now each healthcare company is required to carry out a separate process for verifying credentials.
8 Tips for Speeding Up Physician Credentialing
These eight steps should be included in your organization’s process to expedite physician credentialing.
- Get the process started right now! Plan for 120 to 150 days to finish all certifications as soon as you know you’re bringing a new doctor on board.
- Where appropriate, use technology to speed up the credentialing process and lower error rates.
- When a new doctor enters a practice, setting a string of strict dates for the medical credentialing procedure can guarantee that it moves forward as planned.
- Make sure a doctor’s Curriculum Vitae (CV) is completely updated. Confusion will be avoided.
- All required supporting documentation should be available online.
- New legislation may have an impact on the various state laws governing medical credentialing. To avoid unpleasant surprises along the way, it’s critical to periodically review for updates and modifications and adapt internal processes accordingly.
- Carefully review each payer’s application and provide all necessary details to make sure everything is accurate. Approximately 85% of all applications for medical credentials include incomplete, erroneous, or outdated information.
- Physicians who frequently update and attest with CAQH will find credentialing and re-credentialing considerably easier thanks to the coalition for affordable quality healthcare’s (CAQH) uniform credentialing scheme.
Final Thoughts
Hospitals may become overwhelmed by the substantial credentialing effort since laws and regulations governing provider data and credentialing are continually changing. Reimbursements may be withheld or delayed if a medical practice is late in obtaining necessary credentials. Finally, contact Verisys to find out more about their dependable credentials verification platform if you want to maintain compliance and keep giving the best possible treatment to your patients. Also, consider outsourcing your certification by contacting Verisys
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