Provider credentialing isn’t a topic discussed often in healthcare revenue cycle management. However, more organizations are recognizing credentialing as an essential part of the revenue cycle. Without it, practices and clinics cannot legally bill patients for services or collect revenue. Further, failing to properly credential even one provider can put your organization at serious risk of a compliance violation that could become a liability in the event of a false claim.
Credentialing is becoming more complex from both a legal and regulatory standpoint, yet many clinics and healthcare organizations devote fewer resources to it. But the answer may not be incurring significant costs to add hard-to-find, new staff members with expertise in credentialing. If you’ve been overlooking credentialing in your practice, outsourcing it could be a better choice.
The Credentialing Process
The credentialing process for one or multiple providers usually begins when the provider/group establishes or joins a practice. They must submit information about the place where they intend to treat patients, as well as their personal information and provider number(s). That involves submitting all background information as primary source documents—including education, training, board certifications, professional references, licenses, and any other data relevant to their ability to practice medicine—for hospital or payer staff to validate. If providers also plan to practice in a hospital or cover on-call shifts there, they’ll need hospital privileges—a separate step that follows successful credentialing.
Credentialing also entails submitting the information to any government or private payer that the practice intends to bill for services. This is often referred to as the provider or payer enrollment process. Today, providers typically apply to 20-25 payers (for each individual provider).
Part of the challenge of credentialing is that the process takes time as hospitals and payers review and verify the information (anywhere from 90 to 120 days on average). In the meantime, providers can’t start treating patients or sending in claims. There’s also no standardized process among healthcare organizations and payers. For example, individual payers have their own rules about the timeline for submitting practitioner information. Medicare won’t allow providers to submit their application more than 60 days prior to their requested “effective date.” Even a small delay in submitting the information or an error in the paperwork can delay credentialing and the ability to treat patients, costing your practice in reimbursement dollars and inconvenience to patients and the providers themselves.
How to Improve the Credentialing Process
Credentialing requires staff who are knowledgeable about the ins and outs of the process and resources dedicated to keeping up with changing rules and regulations. For those reasons, many practices and providers partner with a credentials verification organization (CVO) to navigate the complexities of credentialing. These companies are experts at credentialing and provider enrollment, often conducting both for the practices they service.
AdvancedMD partners with symplrCVO, which offers a variety of services, including:
- Initial credentialing
- Recredentialing primary source verification
- Background screenings
- Consulting on proper policies and procedures
- Medical licensure services
- Hospital & facility submissions for credentialing
- Provider relocation enrollment
- Assistance after M&As
To learn more about how symplrCVO can speed the processes of credentialing and enrollment—and ensure that it goes smoothly for all your providers and payers—contact us today.