Credentialing and Re-Credentialing: When a healthcare facility hires a new nurse, physician, or other staff member, they need to go through credentialing or re-credentialing. This process checks the new hire’s skills, qualifications, and other credentials, and gets approval from the insurance providers the facility works with.
Many people think credentialing is done once a provider is accepted into the insurance network, but that’s not the case. Healthcare providers must regularly be checked to ensure they follow federal and state guidelines and can provide quality care. This ongoing process is called re-credentialing.
IMPORTANT: Confidential information gathered during the recredentialing process will be handled and disclosed according to Tranquil’s privacy policies or as mandated by law.
Why Credentialing and Re-Credentialing Is Important?
To ensure that insurance claims are processed correctly, healthcare providers must successfully complete credentialing. This process is also crucial when a patient is uninsured or needs to pay out-of-pocket for their treatment.
Credentialing isn’t limited to physicians; it also applies to other professionals, including:
- Health and hospital agencies
- Physical therapists
- Dentists
- Counselors and psychologists
- Licensed massage therapists
Healthcare facilities must follow specific guidelines for credentialing and re-credentialing to accept Medicaid and Medicare services. These guidelines are set by federal agencies like The Joint Commission on Accreditation of Healthcare Organizations and the Centers for Medicare and Medicaid Services (CMS).
In addition to federal requirements, state credentialing is also necessary. This makes credentialing and re-credentialing a complex and time-consuming process, where even a small mistake can cause significant issues for the entire facility.
Credentialing a Provider: Key Steps
Credentialing a provider typically involves three main steps:
- Data Collection: Gather essential documents like education, license, work history, and certifications.
- Information Verification: Verify all data with primary sources to ensure accuracy.
- Final Credentialing: Once verified, the provider is either approved for clinical privileges or asked for additional information.
A Credentialing and Re-Credentialing Checklist
“Effective credentialing and re-credentialing are essential components of a well-run healthcare facility.” By following specific steps, you can ensure these processes are completed accurately and timely, contributing to optimal patient care and operational efficiency.
1. Documentation
Streamlining credentialing and re-credentialing processes is crucial for healthcare facilities seeking to optimize operations and deliver exceptional patient care. By adhering to specific steps, you can ensure that these critical tasks are completed accurately and promptly, minimizing disruptions and maximizing patient satisfaction.
- Name
- Demographic information
- Social security number
- Education & residency information
- License proof
- Career history
- Patient focus and specialties
- Insurance proof
- Information on your healthcare establishment
Other information may be required by insurance agencies for credentialing or re-credentialing. Be sure to thoroughly review their requirements, prepare the necessary documents, and submit them promptly
2. Prioritizing
Given the number of insurance agencies involved, you must submit credentialing or re-credentialing documents separately for each one. It’s advisable to prioritize insurers and send your applications to them first. Here’s how you can prioritize:
- Start with the insurance company through which a significant portion of your medical billing is processed.
- Focus on insurance companies that offer quick approval and streamlined processes for credentialing/re-credentialing.
- Choose insurance providers that offer an abbreviated application process for in-state credentialing/re-credentialing as they can be a more efficient option.
3. Accuracy
As you start with filling out the credentialing/re-credentialing of the forms and application and preparing the documents, remember to check them because accuracy is the key to getting successful credentialing. The following steps can be followed to ensure information accuracy:
- Background check and verify the documents of practice, board certification, education history, etc.
- Review credentialing history
- Check if the Office of Inspector General has ordered any sanctions
Verification can be performed manually or through alternative methods. Since manual checks are often time-consuming and costly, using options like credentialing software or outsourcing can be more efficient for faster turnaround.
4. CAQH Requirements
Applying through the Council for Affordability Quality Healthcare is required by major healthcare insurers. Check if the insurance agency you are applying for credentialing demands such a requirement. If the insurance company partners with CAQH, then a CAQH number has to be mentioned while submitting the application to the insurer for credentialing/re-credentialing. You will then be required to complete and submit the CAQH form.
Thereby, any error can delay or reject the CAQH approval. Finally, you must re-attest after the submission, which means the information provided is correct.
5. Follow Up
Rather than waiting idly for credentialing or re-credentialing approval, taking proactive steps can lead to faster results. Follow up on your submitted forms by reaching out to a knowledgeable contact at the insurance company and checking in via email or phone. This approach helps expedite the process and ensures you can provide any additional information promptly, minimizing the chances of delays or rejections.
Easing the Strain of Credentialing & Re-credentialing for Providers
Feeling overwhelmed by the credentialing or re-credentialing process with insurance companies? A simple solution is to partner with credentialing specialists such as Tranquil Medsolutions. They take care of all aspects of credentialing, monitor re-credentialing timelines, and manage the extensive documentation, checks, and verifications required by insurance companies. This allows you to focus on your practice and patient care, while the specialists handle the credentialing details for you.
