The Medical Credentialing Process For New Providers

February 18, 2021

If you’re opening a new medical practice, medical credentialing is probably the first part of a very long to-do list. Credentialing is crucial to getting paid as a medical practitioner – just as physicians need credentialing in order to work with insurance companies, their medical business does too.

This post leads you through the basics of medical credentialing for practices, and what you can expect from the process:

Why Do Providers Participate in Medical Credentialing?

Practices seek out credentials because, quite simply, it’s hard for a business to survive without them. On the financial side, credentialing enables you to receive in-network payment from insurers. (Without credentialing, you’ll hardly see a cent from insurers.) 

Additionally, patients generally prefer physicians in their insurance network because in-network services are more affordable. As more insurer networks credential your practice, you expand your potential client base.

Credentials also instill confidence in new patients. It shows that you’re vetted and endorsed by industry peers.

Who Provides Credentials?

Credentials are provided individually by insurers and governmental programs.  For example, if you’re interested in getting credentialed by Aetna and BlueShield, you’ll need to submit applications to each company. This is true for national insurance firms as well as smaller regional insurers. Similarly, a federal program like Medicare requires a separate credential application from state-run programs like Medicaid.

How The Medical Credentialing Process Works

The steps of the process are relatively simple (though each step involves many details):

  • Identify available credentials
  • Compile necessary documentation
  • Submit application
  • Track progress for each application

From initial submission to final approval, the credentialing process can take anywhere from 60 to 180 days for each application. (If there are any errors or confusion with your application, this timeline can be considerably longer.)

One big challenge in the credentialing process is the management of minor details. And the complications are multiplied as you apply for more and more credentials.

1. Identify available credentials

Start off by researching the payers in your area:

  • Which national firms provide service to your community? 
  • Are there any smaller, local firms? 
  • What firms are local businesses using to provide health insurance to their employees?
  • Are many people in the community using Medicare or Medicaid?

Once you know the range of possible payers, you’ll need to figure out which of them are open to credentials for the type of services that your practice provides.

2. Compile necessary documentation

Though the details about documentation may vary slightly between credential applications, there are some pieces that you can expect to provide for all. 

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

Depending on your specialty, you may be required to submit more. If you run a lab, for example, you might need to provide a Clinical Laboratory Improvement Amendments certificate.

3. Submit application

Complete the application with all documentation according to the specifications for each payer. It’s important to make sure every field and document is completed correctly at the time of submission – an application with any errors can force your practice to completely resubmit, which can amount to months of lost time.

4. Track and follow-up

Because the process can be gradual and frustrating, you’ll want to check in with every credential application throughout the process to make sure everything is moving forward on schedule. Consider contacting each credential organization once every two weeks for a status update. 

If you’re tracking applications by hand, a spreadsheet can be helpful to keep all of this data organized. If you’re using a third-party credential service for this process, they should be tracking all applications regularly on your behalf.

Medical Credentialing With Quatris Healthco

Medical credentialing is an essential business step for any new practice – credentials expand your revenue options and connect you to insurer networks that drive patients to your office. Together with our partner Equalizer RCM, we offer a Credentialing and Contracting Service that helps medical practices across the country minimize mistakes and maximize their collections.

Our credentialing service evaluates a provider’s license and certification qualifications and practice history which can, in turn, enhance their reputation and credibility while protecting patients and the practice. Our Contracting service works with the payors to establish an agreement and terms for you to become a participating provider and receive in-network reimbursement for your claims.

Learn more about the world-class services we provide to help new practices get up and running.

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