Medical Credentialing for Physicians & Practices

March 3, 2021

Whether you’re opening a new practice or first establishing yourself in the profession, you’ll almost certainly need to be credentialed with insurers. Credentialing is a step toward partnership with any insurer. It’s a way to secure vital revenue streams. And it’s a way to ensure quality among all new physicians you hire.

Practices and hospitals can be credentialed with insurers. Individual physicians can too. Robust practices get credentialed on both levels. This post will explain how medical credentialing works in both situations.

What is Medical Credentialing?

Credentialing is the process of being formally recognized by medical insurers – public and private. In order to be in an insurer’s network, and grant ‘in-network’ rates to its members, a practice must be credentialed by the insurer. The same goes for physicians.

To clarify what medical credentialing is, let’s compare it to other adjacent terms.

Credentialing vs. Contracting

A contract between your practice and an insurance provider is just that: a binding business agreement. Before you or your practice can arrange that contract with an insurer, you need to first receive their credential.

For medical staff who are not physicians (eg. physical therapists) credentialing may not be required in order to contract. This may vary by specialization, insurance company, and state.

Credentialing vs. Privileging

Privileging is the process by which individual medical staff are authorized to perform specialized care. Gastroenterology, oncology, and pulmonary medicine are examples of specialization that require privileging.

Privileges are granted by medical practices and hospitals. A physician can practice medicine within an insurer’s network without privileging. However, if they’re interested in performing specialized procedures such as surgery, they must apply for the privilege.

The Benefits of Medical Credentialing

It’s hard for a medical practice to thrive without credentialing – credentials open many doors for medical professionals.

Expanded Patient Base

It’s one of the most basic facts of health insurance: patients with insurance are incentivized to use in-network providers. Choosing in-network often saves patients a lot of money on bills – plus, insurer directories make it easier to find an in-network provider.

The more (public and private) insurer credentials you have, the wider your prospective client base. If you avoid credentials, you’re shutting the door to a lot of potential revenue.

Streamlined Revenue Cycle

Which is easier: collecting all payment from hundreds of individual patients or from a handful of insurers? When you’re credentialed and contracted, you can collect payment steadily, efficiently, and more regularly.

Of course, you can still sometimes receive payment from insurance companies if you’re out of network. However, the process is more complicated and reimbursement is less of a guarantee. 

Moderated Legal Liabilities

The credentialing process requires a practice to account for all necessary licensing and qualifications. Individual physician credentialing includes professional references and an examination of work history.

By going through this process for medical staff, a practice is able to thoroughly examine every member. Problematic work histories come to light. Unqualified candidates are easily vetted. Weeding out underqualified staff at the outset is a way to protect yourself against malpractice down the line.

Validated Reputation

On top of safety, quality-control, and financial security, credentialing might also be considered a smart marketing move. It’s an endorsement from peers in the medical industry. When prospective patients see that long standing medical insurers trust your practice, it instills confidence in the legitimacy of your business.

How The Medical Credentialing Process Works

The basics of the process are similar for practices and physicians when applying for credentials:

  • Identify available credentials
    Find the insurers that serve your community. It might be a mix of big national brands and smaller, regional brands, as well as Medicare and Medicaid.
  • Compile necessary documentation
    Every state and insurer has slightly different requirements of documentation. The list covers everything from education basics to professional endorsements.
  • Submit application
    Applications can vary across insurers – and every single application you submit needs to be error-free. Application errors can delay the process for months.
  • Track progress for each application
    In order to ensure the process is moving forward as scheduled, you’ll need to check in regularly with each insurer about each application until everything is complete.

Documentation for Medical Credentialing

Insurers have different expectations for medical practice and individual physicians. The specifics may vary across states and insurers, but you can expect to provide some fundamental documents for each one.

Medical practice credentialing documentation

  • IRS forms (eg. W-9, CP575)
  • Business license
  • Copy of lease
  • Bank account verification

Physician credentialing documentation

  • Education
  • Certification
  • Licenses
  • Work history
  • Clinical privilege history
  • Peer references
  • Insurance claims history

Physicians and practices may also familiarize themselves with the Council for Affordable Quality Healthcare (CAQH). The CAQH is a centralized industry panel that many insurers rely on for vetting credential candidates. Part of the credential application may involve submission to the CAQH.

Credentialing Factors to Keep in Mind

There are a lot of little details that can speed up your application, or slow it down – and sometimes lead to an outright denial. The following are best practices to consider at the outset of your application process.

The process can take a while

Expect it to take at least three months – and anticipate that it could take as long as six months depending on the organizations involved and complications with any given document.

Requirements vary across location and insurers

Create unique lists for every different credential to which you’re applying.

Protocol can change

The rules and requirements that governments, companies, and industry boards set for credentialing do change from time to time. Staying up to date with these changes will ensure a speedier process and fewer headaches.

Credential delays lead to reimbursement delays

The longer it takes for your practice and staff to get credentialed, the longer you’ll endure payment processing hassles and delays.

Changes in an application require resubmission of attestation

You might not need to complete a new application but you’ll need to attest for it. It’s a small detail that, if overlooked, can slow everything down.

Tips For The Medical Credentialing Process

Your practice can set itself up for success by putting these in to practice.

Decide On A Workflow

The life of a credentialing application is mighty involved. Who will onboard new staff for credentialing? What will the most efficient sequence of events be? 

Mapping out the process for your practice ahead of time – and assigning point people for each step – will keep the process efficient, effective, and low-stress.

Establish Quality Controls

One tiny error on an application form can force you to begin the process all over again. The tiniest oversight can set your business back months in this way.

Set up systems to check every detail of every application exhaustively before submitting them to insurers. This might mean sending applications through several administrative people, or using an application platform that automatically scans for errors.

Schedule The Process Into Your Hiring Protocol

An ideal, error-free, speedy credentialing process still takes several weeks – and often several months. Factor this into your human resources plan.

Plan for new hires to start seeing patients at least two months *after* hiring, because of the credentialing process. And make the official start date dependent on credential approval.

Create A Credentialing Guide For Staff

Success in credentialing staff depends just as much on the individual applicants as much as your administrative team. Set the applicants up for success.

Provide a clear, step-by-step document that applicants can use to collect documentation and complete applications according to your exact needs.

Keep A Digital Storehouse

Multiple staff submitting applications to multiple insurers, and each one with a unique set of required documentation… it piles up quickly. And some credentials will need to be updated years down the road.

Set up a central filing system for all necessary materials. Make sure it’s accessible but secure. 

Track Every Application From Start to Finish

If there is a complication with any submitted application, you might not hear about it for weeks or months down the road. Any delay in the process is an unnecessary financial hindrance for your business.

So take the initiative to make sure that every application is moving as speedily as possible. This means checking in with insurers consistently about the status of each application until the process is complete. 

Tracking is a major part of the process – and it’s one reason why many practices use a third-party service for credential applications.

Medical Credentialing With Quatris Healthco

If you’re trying to run a robust medical business, medical credentialing is a necessary step. This is true for hospitals, small practices, and individual medical staff.  The process itself is time-intensive, detail-oriented, and varied according to location and insurer. Anyone applying for credentials must be meticulous as they assemble documentation and complete forms and minor mistakes can set the process back months and slow down revenue for your business.

At Quatris Healthco, our credentialing service helps medical practices across the country minimize mistakes and maximize their collections. Evaluating a providers qualifications and practice history enhances their reputation and credibility while protecting patients and the practice.

Is a credentialing service the right choice for you? You can explore the options with Quatris Healthco.

Schedule your free Key Metrics review!