A Provider Credentialing & Contracting Checklist
A credential provider gets an increased number of patients through referrals from payers. Further, credentialing assures the patient that they are getting treated by a credible provider. It also helps physicians expand their business. Physicians/providers must credential themselves, i.e., enroll and attest with the payer's network and get authorized to provide services to patients who are members of the payer's plans.
What is Physician Credentialing?
Credentialing is a primary process that verifies if the Provider satisfies the following criteria:
Has an unrestricted license
Any disciplinary actions or sanctions by insurers, hospitals, licensing boards, or professional organizations
Presence of any criminal history
Is the Provider certified by the medical board?
General health status
The credentialing process validates if a physician meets standards for delivering clinical care. It usually takes 60 – 120 days for a payer to get credentialed.
This article brings a few things that need to be checked off to ensure a hurdle-free credentialing process.
Steps to File Credentialing Applications accurately
A good provider application is the first step to success in the credentialing process. A provider himself can fill this application, or he/she can outsource this process to an experienced Credentialing specialist. An accurate application will consist of all details, including:
Provider start date in practice
Copy of state license
Copy of DEA
Provider DOB and SSN
NPI #
Updated CV- work history
NPPES logons
CAQH logons
Malpractice incidence details
Copy of Degree/Diploma certificates
Copy of Driving License
Group Name
GNPI & Tax id
Practice and billing address along with Phone and Fax #
Signed W9
Importance of CAQH database for Physicians
CAQH stands for "Council for Affordable Quality Healthcare." It is an online database that stores provider information. Providers grant access to their data to insurance companies through CAQH, making acquiring provider information more manageable. Almost all of the National Health Insurance Companies use CAQH, which makes it a prerequisite for their enrollment process.
There are three steps to getting set up in CAQH.
Obtain your CAQH ID (within 2-3 business days)
Set up your secure username and password
Complete the online application and send in the required documentation
Send your attestation for signature, which certifies the application
Grant insurance companies access to your online application
Not having a completed, up-to-date CAQH application will delay your enrollment with the insurance companies. Furthermore, this will prevent you from getting reimbursed for your services.
Consistent follow-up with the payers
After submitting the provider credentialing application to the payers, the Provider or the credentialing team should ensure that they follow-up once in 5 days. Frequent follow-ups enable you to catch applications with errors or rejected applications faster and re-submit them in a short span.
Payer Contracting
A successful Credentialing approval is followed by a process that associates the physician with the payer's network. This process is known as Payer Contracting. Typically, the payer will share the standard reimbursement rates and the traditional plans such as HMO, PPO, WC, and Auto insurance. While contracting, a provider should ensure that he/she:
Is adopting an insurance plan that is suitable for his/her business
Negotiates a fair reimbursement rate for the services provided
Appeals to open the panels of the networks that are closed for new providers
Post Credentialing and Contracting – Importance of Maintaining Provider Data
Insurance directory Submissions
Providers must keep their details and contact information updated in the provider directory to provide accurate information to the patients. A provider should insist on including these details while completing the insurance directory verification and edit the information as & when required:
Provider name and educational qualifications
Practice Specialty with board certification details
The legal business name that he/she has been practicing with currently
The correct phone number for booking appointments or clarifying any other queries
Adding / Deleting providers for Provider groups:
A practice running a group facility with more than one physician should consistently update any additions or deletions in the group for un-hindered reimbursements. The practice administrator should report:
Any addition of new Physicians / Mid-level providers to the provider group for addition to the contract as well as the insurance directory
Any deletion of existing providers from the group for removal from the contract & the insurance directory
Maintaining Provider Information
The significance of maintaining provider information lies in ensuring that provider information is updated as needed. A practice must ensure that all Provider' information, such as contracted payment terms, name, address, tax id number, and newly gained certifications, is kept current.
With medical technology advancing at rocket speed, healthcare facilities see no end to their exponential growth in size and capacity. While largely overlooked, the key to hospitals performing with quality care and professionalism is the rigorous behind-the-scenes work of their medical staff, making physician credentialing to hospitals' uninterrupted operations.
MBW’s Credentialing and Contracting Services
Outsourcing physician credentialing to a reliable and professional physician credentialing service provider like Medical Billing Wholesalers offers hospitals, provider groups & individual physician practices the support they require for becoming a successful healthcare provider.
Medical Billing Wholesalers has more than a decade of experience with Provider credentialing & enrollment services. With a streamlined credentialing workflow and a team of credentialing & contracting experts, we reduce paperwork and costs while accelerating your credentialing processes.
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