The Do’s and Don’ts of Credentialing

Provider credentialing and enrollment is an absolute necessity when running a successful physician practice. Becoming a provider with commercial and government insurance companies allows you to maintain steady patient referrals and cash flow which is the backbone of any successful practice. 

The concept of credentialing is relatively straightforward. You send information about a physician’s or provider’s qualifications—work history, education, certifications, licensure, and so on—to a payer for review and verification. After they go through a thorough vetting process, the payer confirms the provider and begins reimbursing him or her for services rendered.

Sounds simple, right?

The reality is executing a consistent and reliable credentialing program is not always that easy. Over the years, eMDs has worked with independent physician practices, hospital-based groups, facilities and health plans on their credentialing and enrollment needs. And in that time we have amassed a good deal of knowledge of the Do’s and Don’ts of credentialing. We will share a few of those in this blog post.

Don’t Gloss Over the Details

The most common mistake associated with credentialing is a lack of attention to detail. Application errors can lead to delays and potentially denials. A typical credentialing application will ask for practice address, phone, fax, contact information, services provided, copies of your licensure, employment history, average patient profile and any records of past legal troubles regarding your medical practice.

Omitting or making mistakes on any of this data can lead to delays in your provider credentialing, and it can sometimes be grounds for a denial.

The solution? All your provider applications should go through a rigorous review process to certify accuracy before it is submitted to committee. Getting it right the first time means you'll get a new provider credentialed faster.

Do Allocate Enough Staff

Credentialing is a labor intensive process – the emphasis on LABOR. You need people to manage the process, enter the data, fact check the reporting, and the list goes on. Not having the appropriate allocation of staff can lead to mistakes, which will lead to delays, which will ultimately impact your revenue flow.

Don’t Assume Everything is OK

You know what they say about people that assume things…In credentialing and enrollment, no news does not necessarily mean good news.

Many plans are backlogged with credentialing applications.  Make every effort to confirm your application was received and where in the process it is. If something sounds like it does not make sense, question the response.  We often hear “I have no record of the application” and when presented with evidence of receipt via a trackable transit confirmation, the answer changes to “Oh, it is on my desk."  Make sure you understand the answer before you accept it.

Follow-up at regular intervals and keep notes.  Phone if you need to, e-mail your contacts and check web directories.  With few exceptions, plans will not call you with updates or reasons for delays.  The only way you will know is to follow-up on a regular basis.  No one is more concerned about your application than you.  Make follow-up a routine and planned event which does not stop until the application is approved and participation is secured.

Do Start Early

Many practices get started too late, which can be a matter of success and failure for your practice. At a minimum you want to give yourself at least 90 days. Realize that you are working on someone else’s timeline – the payer. The responsiveness of the payer to your application will be determined by their workload and their motivation to add new providers to their network.  As payers have merged and supersized, a practice's ability to expedite an application has shrunk.

Credentialing your medical providers is labor intensive with few shortcuts. Yet practices need to maintain participation in a wide range of plans to remain competitive and to facilitate scheduling, coverage, timely payment and most important, keeping referrals within the organization. Working with a credentialing company can help you complete each phase without delays.

To learn more about eMDs credentialing services, contact us today for a free consultation. 

Join Our Newsletter

Get Updates Direct to Your Inbox. Gain access to a rich library of articles, white papers, webinars, podcasts and more. Register today to receive eMDs Insights newsletter.

Specialty *
State *