How Do I Get Credentialed with Insurance Companies? Credex healthcare guide

Credentialing with an insurance provider is one of the top steps a healthcare provider can possibly do. Especially prior to engaging patients. The outcome of credentialing is that the providers must be qualified, licensed, and satisfy all the obligatory customs required by the insurance companies. 

This process is not only necessary in legal and compliance considerations but also in terms of payment and increasing patient base. Healthcare is increasingly becoming insurance-based where providers must be identified by insurers to be included into their networks to provide services to covered patients.

Credentialing is not forms and it is not record keeping but it is about schooling, training, licenses, experience and certification. Insurance companies desire to be sure of the fact that providers, which they incorporate into their networks, are of the supreme quality. 

Credentialing is needed in order to be able to bill the insurance companies and uncovered patients can go to a provider who is already credentialed. This might be a complicated process but is an essential element of establishing your practice and developing trust among patients and payers.

Credentialing also helps you in establishing professional credibility. Patients usually verify that their provider is within the scope of their insurance cover and insurances verify current credentials before processing claims. 

Credentialing is also a legal prerequisite. Well in most states, to charge Medicaid or Medicare. This intensifies the significance of punctual and precise credentialing even more.

Who Needs to Get Credentialed?

Credentialing must be done on all types of providers. This involves individual practitioners, group practices, behavioral health, physical therapy, dentists and any other licensed medical practitioner who intends to invoice some insurance company/companies with his/her services. 

Even urgent care centers as well as clinics have to undergo this procedure. Insurance companies need you to be credentialed by them irrespective of where you practice or your specialty to utilize your services.

Even practitioners with advanced degrees and roles such as the nurse practitioner (NP) and physician assistant (PA) need to be credentialed. It is known that Imaging centers, labs, hospitals, and behavioral health facilities are among those that fall under this credentialing umbrella also. Regardless of your profession in patient care, credentialing is needed in case you are bound to work with insurance reimbursement.

Step-by-Step Guide to Getting Credentialed

To begin your credentialing adventure, you should get your National Provider Identifier (NPI). This is an identification number, given by the National Plan and Provider Enumeration System (NPPES) to healthcare providers. You may apply online and your NPI is used in every transaction with the payers.

Once you have your NPI it is important to ensure correct licensing in your state and ensure all credentials are up to date. These are your professional license, board certifications and malpractice insurance.

Then you have to complete the registration process by going to CAQH ProView. It is known to be some kind of universal application program many insurance companies use. The Council for Affordable Quality Healthcare also known as CAQH. 

It helps to enable the storing of their information in a central repository. This profile has to be filled completely and considered regularly. When you become credentialed with an insurance company they will also look at your information using CAQH. You should bear witness to your CAQH profile on a regular basis to ensure its activation.

Well, Enrollment applications should be made to every insurance payer. This occurs after enrolling with CAQH. Every payer can be different in form, portal, and requirements. Aetna, UnitedHealth Care, Blue Cross Blue Shield, Cigna and Humana are among some of the most common insurance companies.

Such applications would normally request your practice information. They would also go for medical qualifications, insurance and contact information. This always happens when one submits each of the sections. Then later resubmission to avoid delays is important.

When applications are submitted, it is your turn to follow up and keep up with the process. Insurance companies may demand any further evaluation or update in your details and non-response will slow up your acceptance. Well, the norm is to wait 60-120 days in order to have the credentialing performed.

At this stage, it is convenient to keep all the submissions, code numbers, and contact with insurance representatives. Other providers can rely on a credentialing program or Credentialing spreadsheets to remain organized. They can be advanced with 2 to 3 weeks follow up calls or mails.

Required Documents for Credentialing

During the course of the process, some documents are needed. These are your NPI, your medical license, DEA registration, certificate of malpractice insurance. This also contains board certification and a copy of your CV or resume, W-9 form and a government issued ID. Existing or expired documents are one of the major causes of delays in application. This is done smoother when you have your paper work ready beforehand.

The practice locations and Tax ID number, group NPI (when available), business liability insurance should also be provided. Make documents legible and in PDF or other acceptable file formats all the time. Make all the papers consistently prepared and available in case something needs to be re-presented.

Common Challenges in the Credentialing Process

Most of the providers encounter some of the following problems in the process of credentialing. The inability to fill out a CAQH profile or sign the CAQH profile is among the common problems. 

The other issues are the lack of documents, loss in communication with payers, or just failure to follow up with the application. Every single mistake may provide big delays. Providers are left with no choice but to be aggressive and thorough during this process.

The second critical obstacle is payer-specific criteria. Other insurance companies require special preparations, such documents notarized or visits to the location. Background checks or verification of a license are also a slow approving procedure. It is good to address applications on time and ensure not to make incomplete applications.

How Long Does the Credentialing Process Take?

Credentialing can take time and the duration taken can rarely be estimated depending on the number of factors that affect his duration of completion including the internal process of the payer, the type of provider you are and the completeness of your submission. The length of the credentialing process is between 60 to 120 days. 

Nevertheless, practice can drive this schedule back in case of error or lack of documentation. The most effective way of making sure you are prepared to see patients once your practice is opened is by planning early and commencing the process as soon as possible.

Other payers provide accelerated credentialing processes, but only to the degree of specialty or of shortage of providers. Ask at all times whether there is a fast track. Remember the timeline can take months even in the case when you are re-credentialing.

Can I Get Help with Credentialing?

Due to the intricacy of the credentialing process, a lot of providers decide to employ credentialing firms. Such firms major on the control of the entire process, i.e. NPI registration and final payer approval. 

A credentialing service may save your time, decrease the number of mistakes, and guarantee prompt approval. In selecting a credentialing company seek experience, openness and an understanding of your specialty. An effective credentialing partner will update you along the lines. They will also lead you throughout.

Also credentialing professionals keep themselves aware of payer requirements that continuously change. They are able to do re-credentialing, monitor the status of the application and correct any errors, which otherwise would have remained invisible. When you outsource, you gain back time in order to allow you to concentrate on what is most important to your patients.

Credentialing vs. Contracting

It is also good to know the distinction between credentialing and contracting. Credentialing is a practice that validates your sponsorships and approvals, and contracting is when an arrangement of agreement between a payer. It is something you signed so that it makes you in-network. Credentialing should also be done before you get into any contract. In the absence of the two steps you cannot make insurance claims and get payments.

Credentialing is the background check and contracting is the job offer. It is upon passing the credentialing stage that the payer will offer a contract of agreed reimbursement terms, billing policies and the effective dates.

Other Common Questions

There are providers who ask themselves whether they can charge some insurance at the time when credentialing is in progress. And the answer in most situations will be no. Insurance companies will not pay you when you are not in their network. It is because of credentialing problems. There are payers that accept retroactive billing but they are not always guaranteed and it is not recommended to rely on it. Probably the better approach is to wait until you have your contract and start the billing date.

In case your practice has several locations, you might be required to complete individual credentialing applications to each of your practice locations. This is according to the policies of the payer. Remember to clearly state the list of practice addresses in your application since this might be confusing. Likewise, you are required to update payers in case you alter your practice address or modify your license.

It is worth hiring a person to do credentialing on your behalf. Credentialing companies are knowledgeable about the payer processes, requirements on documents, and frequent problems. They are able to follow up on the applications, keep them and can tell that every application has been put where it should have been. The benefits of outsourcing credentialing are that providers will not be stressed with credentialing paperwork.

Final Thoughts: Start the Credentialing Process the Right Way

To sum up, credentialing in insurance companies is an extremely important process of a healthcare provider. It helps you to comply with the expectations of payers and earn your services to be reimbursed. Though the process might appear to be overbearing, it can be handled through a step-by-step guide and remaining organized. 

You can carefully plan, document the right way, and, in case you need some assistance, employ credentialing professionals and go through the process easily without any difficulties getting accepted as an in-network provider and start treating your patients.

To make sure you will not encounter some delays and start your practice on the right foot, it is essential to begin early and keep track of the details with Credex Healthcare.

FAQs About Insurance Credentialing

What is provider insurance credentialing? 

Insurance credentialing is the naming process through which insurance companies certify their provider in terms of qualifications, licenses and background thus teleporting to their membership in the network.

What is the initial step to the credentialing process? 

Begin by registering your own NPI, building the documentation and making a CAQH profile, and then Afterward, you can start applying to payers.

How much time does the process to be credentialed with insurance companies take?

 Its average payer-dependent time frame is between 60 to 120 days depending on the availability of the documentation.

Do I have to get credentialed with every insurance company by the name?

 Yes, It is true. Every payer is different, but CAQH simplifies certain forms of data exchange.

Can credentialing be done by another person on my behalf? 

Yes, a lot of the providers enlist companies that perform professional credentialing services to decrease the timeframes of delays.

Is post-ethical credentialing possible? 

There is the practice of retroactive billing within some payers though this may not always be the case. Check it out ahead of time with every payer.

Should I renew my credentialing information? 

Yes, you should. It also updates your documents and profile on CAQH in response to address or license change and ownership changes.