What is Insurance Credentialing? Healthcare Providers

The term Insurance credentialing refers to how insurance organizations validate whether a medical practitioner is genuine, licensed, and competent to see patients. This involves ensuring that you fit the criteria of the payer such as Medicare, Medicaid, Aetna, UnitedHealthcare, Cigna and BCBS. 

When you are credentialed, you are allowed to join insurance panels, accept insurance using patients, and receive compensation on your work. The first step of procuring credentialing towards legal, patient trust, and financial success in your practice starts with credentialing.

Understanding Insurance Credentialing in Healthcare

Insurance credentialing concerns the verification of your education and training, license, certifications and background. It does not amount to contracting. The purpose of credentialing is to assure who you are and what your capabilities are. Contracting is the act wherein you will enter into a legal agreement with the insurance company. 

Well collectively, they form a revenue cycle and reimbursement process. Papers require credentialed providers to offer safe and quality care, adhere to the provisions, and settle claims. There is no credentialing, whereby you are unable to bill insurance or be a part of their network.

Who Needs Insurance Credentialing?

It is hereby that Credentialing is required by any license provider wishing to treat patients with insurance cover. These are the physicians (MD/DO), nurse practitioners, physician assistants, and mental health counselors. Physical therapy institutions, clinics, and behavioral health institutions should also get credentialed. Here new graduates embarking on a practice should also initiate the credentialing process before patients can be seen under insurance cover.

Why Is Credentialing Important for Providers?

Acquiring credentials opens a lot of doors. To begin with, as a result, you will have an opportunity to join insurance panels and interface with more patients. In case of its absence, patients will not be able to cover your services. 

Second, credentialing develops trust in the patients. Payers probing into your qualifications is one thing that can help the patients be convinced of your credibility. 

Third, it assists in complying with the legal and regulatory details. Credentialing should be a major concern where audits should be avoided and compliance to CMS, Medicaid and Medicare should be maintained. 

Lastly, it makes sure that you get paid. No credentialing equals no billing and no reimbursing.

How Does the Insurance Credentialing Process Work?

Preparing NPI and License

The first thing to go through is receiving your National Provider Identifier (NPI) through NPPES. This is a number that must be in all billing and payer programs. Next, make sure that you have an active state license. 

But in case of a prescription of any type of medicine, you should obtain DEA registration as well. Make malpractice insurance up to date and collect all your board certifications, resume or CV, W-9 form, and taxonomy code. The documents here are the spine of your credentialing application.

CAQH Registration and Attestation

The majority of payers retrieve the information about providers via CAQH ProView. Make your profile, tabulate your education and work experience and apply all your licenses. Each 120 days you have to renew and certify your CAQH profile. 

This information is retrieved by the insurance companies in the course of credentialing, hence it should always be up to date and error free.

Submitting Credentialing Applications

Then, make an application to every payer panel. Credentialing requirements by insurance companies are different. Others will need PECOS enrollment to Medicare and Medicaid. All you need is to fill in all the payer enrollment forms, submit documents and submit all early. Design a credentialing checklist to avoid forgetting something and be organised.

Verification and Approval

Here payer credentialing departments request and review your application and properly do credentialing verification. They validate your NPI, license, CAQH profile and the rest of the documents. 

This might prove to be time-consuming. They can require additional papers/information. The plan of credentialing also allows you to track the progress. Paperwork may also cause delays in the process that takes an average of 60-120 days.

Contract Signing

After the verification, a network participation agreement will be sent to you. This legal contract spells out your rates of reimbursement, your billing regulations and the starting out date. Contracting is accomplished by signing this agreement. Once you have contracted, you are an in-network provider and will be able to charge accordingly.

Key Documents Required for Credentialing

Insurance credentialing is a procedure which demands various forms. You require NPI, state license, your CAQH profile, resume or CV, board certifications, DEA registration (mandatory in cases of DEA registration), malpractice insurance certificate, W-9 form, and photo identification. Other payers might also request your Tax ID, list of practice locations and federal practice address. All the papers must be up to date and in a clear legible manner.

How Long Does Insurance Credentialing Take?

The process of credentialing normally requires 60 to 120 days. The schedules can be different based on what the payer requires, what is a type of your provider and how quickly you are able to fill the papers. The enrollment process may take a longer time by using PECOS at Medicare. 

Credentialing is usually bogged down by delayed CAQH attestations or the lack of documents. Shortage of a particular provider may be credentialed on an accelerated (or expedited) basis and should inquire with the credentialing department of your payer as to whether this is applicable to you.

Common Challenges During Credentialing

There are a variety of barriers that credentialing tends to face. A submission can be halted by CAQH attestation(s) that are absent, expired, or incomplete; incomplete license or DEA registration identifiers; or an erroneous W-9 form. 

There are also delays in communication and calls not received by the payer through their email. The various payers can request various format files or even notarized ones. In order to avoid interruptions practice owners should maintain a credentialing checklist, pursue each application and inquire into the progress as well.

Can I Handle Credentialing Myself or Hire Help?

There are providers who perform credentialing internally. This can be achieved freely in case you have time, tolerance, and organizational ability. You have to follow up the timelines, discuss the payer credentialing representatives with payer credentialing, and make them comprehensive. Most providers want to cooperate with credentialing service providers such as Credex Healthcare. 

These experts deal with the NPI registration, CAQH maintenance, payer enrollment, PECOS, and contract negotiations. When you hire assistance, the process is accelerated, and the level of error is decreased, and you have an opportunity to work with patients.

Conclusion: Insurance Credentialing Is the First Step Toward Payment

Insurance credentialing is important and cannot be compromised by any individual provider that wishes to deal with the insurers. It secures your credentialing; it makes you establish credibility, becomes legal, and you can also bill and receive payment. Insurance credentialing means that you want to have your NPI ready, apply in CAQH, send them to payers, and wait until they are approved, and sign contracts. 

Although it is possible to spend 120 days on it, proper planning, attention to details and monitoring help. So, no matter whether you simply do it yourself or hire a credentialing service, early is the one of the secrets to getting the most out of what you are earning.

FAQs About Insurance Credentialing

1. What really is insurance credentialing?

Insurance credentialing refers to the process of qualifying a healthcare practitioner to avail of insurance panels and get reimbursement to treat patients.

2. What is important about credentialing?

Credentialing will make the payers verify you, patients trust in your services, and billed insurance will be able to pay you legitimately.

3. What is the timeline of the credentialing process?

The usual time taken in insurance credentialing is 60 to 120 days. One of them can be the delays in case of missing or incomplete documentation.

4. Are credentialing and contracting the same?

No, here credentialing is to check credentials and contract involves an agreement to network terms and acceptance of agreement with the insurer.

5. Which documents are to be provided in the credentialing?

You will require NPI, state license, CAQH profile, resume/+ CV, board certificates, DEA registration (as applicable), malpractice insurance, W-9 and ID.