Best Practices for Credentialing Success


When I was a child, my friends and I wanted to fly using jetpacks or skateboards with powerful engines. Today, personal hoverboards are a reality, but the technology doesn’t quite deliver the experience that we hoped for. For me, credentialing software programs fall into the same category—they work, but they aren’t a complete solution.

The credentialing software programs that our firm has used, or that we’ve considered using, act as efficient repositories of information. The shortfall occurs when communicating that information to the myriad of health systems, payers and government organizations that need access to the information—each with unique requirements and formats. Until there are standard and universal credentialing requirements, we still need highly trained and efficient humans to ensure that documentation is provided on time and in the proper format.

Credentialing has a direct impact on revenue cycle and provider success. It should be a continuous process with dedicated resources, which is why many practices choose to outsource this critical function to experienced firms. Below are four best practices for credentialing that will save providers and medical practices time, reduce stress and help to ensure uninterrupted income.

1. Start early.

Many medical practices begin the credentialing process too late, which can lead to providers not being paid for services rendered. At a minimum, begin credentialing 60-90 days prior to start date. The earlier the better, and always assume the process will take longer than you think. Even when applications and forms are 100% accurate, practices and providers can still experience delays when health systems and payers have a backlog of applications.

2. Get organized.

Make sure that you have all of the necessary documents for your credentialing portfolio and develop an effective filing system. Every time you have to dig around for a document that you can’t find or have to perform additional unnecessary clicks to access an electronic folder, you’re wasting time and losing money.

The majority of credentialing organizations now require electronic submission of documents. Since you’re going to have to be credentialed or re-credentialed for the rest of your working life, it’s best to develop an electronic filing system. Your system should be organized with a clearly defined and consistent document naming convention.

Placing keywords in the names allows you to perform searches for all types of electronic documents including pdfs and Word documents. Identify documents by date, or at least by year, in the name. For example, a document named “CV Mary Jones Sept 2018” clearly identifies the content and version.

Create an organized filing system for at least one hard copy of each document as well. Providers should keep their original documents in a secure, fireproof box.

3. Enroll with CAQH.

The Council for Affordable Quality Healthcare® (CAQH) is a not-for-profit collaborative alliance of the nation's leading health plans and networks created to streamline the business of healthcare. CAQH’s database gathers enrollment and credentialing data in a single repository that may be accessed by participating health plans and other healthcare organizations.

Most payers require CAQH be fully up to date with the provider’s practice information, licensure, malpractice, etc., before they will begin their credentialing process. This is a crucial step prior to submitting any applications to insurance carriers.

There is no cost to providers to participate. Health plans and other healthcare organizations pay a set fee per provider to access information from CAQH’s database. CAQH profiles must be re-attested and updated on a quarterly basis. By being proactive and keeping it current, you will avoid delays in credentialing and re-credentialing.

4. Manage your progress.

Once you or your credentialing partner has submitted the application, follow up on a regular basis as to its status and stay in close contact until you receive official approval. Effective credentialing firms identify and develop good working relationships with individuals at insurance carriers to ensure timely and successful applications. If your application has errors or is incomplete, early notification and quick action can save days or weeks in the process.

Secure Your Revenue Stream

Providers must maintain licensure and be credentialed by insurance companies and healthcare facilities in order to be paid for your work. By following the four time-tested credentialing best practices outlined above, you will save time, reduce frustration and help to ensure that you are eligible to receive the compensation you deserve.

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