A renowned, qualified doctor with years of experience is what one seeks when one needs medical care. How does one make sure that the doctor has adequate abilities?
Medical Credentialing is the answer to this question.
What is Medical Credentialing?
Medical credentialing is a process whereby all healthcare providers are thoroughly examined to verify their credentials, which include their expertise, license, professional experience, and education.
Insurance companies and medical organizations do this verification to ensure that the medicals service provider has adequate capabilities to provide patient care efficiently without any malpractice. Compliance with regulatory bodies is necessary.
Healthcare is not the only thing at stake here; finances are, too. Medical credentialing services are required for the healthcare providers to be included in a health insurance network; if it is not done, reimbursements cannot be received.
Types of Medical Credentialing
There are two types of Medical Credentialing:
Initial Credentialing
This verification is done before one starts their medicals practice officially. This type of medical credentialing is fresh off from the start and encompasses all; background checks, qualifications, certifications, work experience, history of disciplinary actions, and more.
Re-credentialing
Re-credentialing helps maintain the standards that govern healthcare providers. This type of medicals credentialing periodically reviews all healthcare providers’ performance, competence, and compliance. Typically, it happens thoroughly once after three years.
Provisional Credentialing
Provisional Credentialing is a preliminary form of medical credentialing where a brief review of the medicals practitioner’s background is done while the full credential application is processed. This allows the healthcare providers to continue their practice until their full credentials are reviewed,
Medical Credentialing Process
Gathering Information
The first step in this process is to collect all data representing relevant information related to the individual (education, license, certifications, etc.). This happens through an application process where all required documents are submitted.
Verifying that information
Primary sources of the collected information should be verified to corroborate the details. This includes medicals schools, education boards, workplaces, and state licensing boards. All of the documents should be attested in compliance with the regulations.
Evaluation of the Information
The verified information will then be evaluated following the healthcare organization’s or insurance company’s requirements. The evaluating committee will also review the practitioner’s clinical skills, treatment results, and compliance with regulatory boards.
Drawing up the resolution
Based on the evaluation, the committee will develop a set of recommendations: grant or deny enrollment to the medicals practitioner.
Notifying the relevant parties
The medicals practitioner, related staff and the other relevant parties will be made aware of the decision immediately.
Reapplying Process
There should be a procedure in place for healthcare workers to apply to reevaluate their medical credentials if they have been rejected.
This entire process can function smoothly if there are basic ground rules that account for the verification of the documents.
To make medical credentialing even smoother, it is important to incorporate the following two things into the process:
- Credentialing software: Tracking of application status, maintaining records, verifying if all documentation is complete; a good medical credentialing software can do all this and more.
- Updates: Staying updated with all the changes in healthcare regulations or insurance policies is important. Verification requirements might change over the years.
Those who are getting their medical credentialing done should ensure that the documentation is accurate and in compliance with the current healthcare regulations.
Importance of Credentialing in Medical Billing
Acquiring accurate credentials of medical practitioners is beneficial in many regards. Let’s see how it benefits medicals billing.
Financial Implications
To receive reimbursements from insurance companies, medicals credentialing is a necessary step. Claims are processed only after the healthcare provider’s legitimacy is ensured.
Fosters trust and credibility
Being tended to by qualified professionals helps boost the patient’s trust. Insurance companies’ endorsement of healthcare providers adds to their reputation and credibility.
Maintains compliance
Medical practitioners with valid experiences and exposure would be aware of governmental regulations to a higher degree. Compliance will be maintained.
According to the American Hospital Association, healthcare providers must comply with 629 regulatory bodies to keep providers licensed.
Reduces Medical errors
When the healthcare providers are experienced, skilled, and compliant, there is negligible room for billing errors or fraudulent claims. This, in turn, saves both the practitioner and the patient from legal and financial problems.
Enhancing the Healthcare System
Medical credentialing paves the way for an increased number of legitimate medicals providers, deterring the rise of fraudulent medical practices. It makes access to healthcare more efficient and safe.
Common Errors in Medical Credentialing
From the Provider’s side:
Limited staff and administration
Medical credentialing is a tedious process that requires great attention to detail. The collection and organization of data are only some of the tasks; verification and evaluation need even more precision. Having a bigger team with a clear division of labor will help quicken up the process of medical credentialing.
According to the Medical Group Management Association (MGMA) ‘s poll in 2021, around 54% of medicals practices felt an increase in denials related to medical credentialing. This is attributed to long delays caused by limited staff and a lack of communication between payers and medical practices
Accepting incomplete applications
The first step while verifying medical credentials is to see if the documentation is complete. If it is not, it should be stopped to avoid reimbursement delays due to claim denials.
Allowing the practice before completing credentialing
Having false credentials is a crime, and medicals organizations are held liable if any problem occurs before medical credentialing has been completed.
From the Practitioner’s side:
Having insufficient documents
Lack of relevant documents will lead to incomplete documentation, resulting in delayed acceptances. Thus, before submitting, the application should be thoroughly reviewed.
Not updating documents
It is important to keep up to date with all compliance regulations. Along with this, all documentation should be in accordance with federal and state laws, which means all expired licenses should be renewed.
Not reacting to adverse actions
In the past, if the medicals practitioner has resorted to any fraudulent activity, then it should be disclosed in confidence. It is better to find out from the provider directly than from the Office of Inspector General (OIG) exclusion list.
If currently, they find themselves as a spectator of such an activity, it is better to immediately alert the authorities (the recommended one is National Practitioner Data Bank (NPDB).
Bottom Line
Medical credentialing companies help maintain medical workers’ and medical billers’ competence. It is important that the system only incorporates those who respect it.
According to a 2022 report by The Beryl Institute-Ipsos PX Pulse, most patients have diminished their healthcare trust. This has various causes and many root causes, but the legitimacy of medicals practices can certainly make amends, even if minor ones.