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Medical Credentialing 101: Hurdles and Pitfalls

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What Is Provider Credentialing?

Provider Credentialing is the process of verifying a medical provider’s education, training, applicable licenses, career history, and any additional specialty certifications required of a health care professional. This verification process is absolutely necessary for the purposes of: 1) obtaining hospital/ASC privileges in which the practitioner can perform medical cases 2) to be properly reimbursed by a health insurance payor company.

Based on state and federal government requirements, health insurance companies and other payors require the credentialing of physicians, nurses, and/or allied health professionals in order for the practice they are employed by to be reimbursed for their services. It also ensures the healthcare professional is properly educated and thoroughly vetted in the specialty(s) they’re recognized in.

Credentialing can take anywhere from two to four months depending on the agency in question and their current workload. Government agencies, such as Medicare and Medicaid, can take up to as long as six months to approve an application. The process of credentialing is onerous, tedious, and relatively easy to get wrong, resulting in long delays which then result in a loss of revenue for the provider. This is why many practices have taken to outsourcing their credentialing.

The Many Hurdles and Pitfalls of Medical Credentialing

There is a myriad of ways in which a credentialing application approval can be delayed. The most common credentialing issues that cause the most headaches are partial, incomplete, and/or missing information on and accompanying an application.

The most common mistakes, aside from incomplete or incorrect information on the application, are misspelled names, using the wrong NPI numbers, and an incomplete lockbox address. Making sure you have all of these correct will help ensure your application doesn’t get held up.

Even when all the information submitted in the application is 100% complete and accurate, there are still a number of things that can go wrong and delay the approval process. Depending on your system, faxed pages can go missing or become illegible, pages can be misplaced or lost in the transfer, or sent to the wrong recipient, etc.

It’s crucial to cross your t’s and dot your i’s, double-check, and follow up after submitting credentials and information, to confirm receipt and nothing is missing.

Taking Time to Shorten Approval Time

The credentialing process cannot be rushed. Time must be taken to ensure the accuracy and completeness of every aspect of the application, every step of the way. Planning carefully and starting the credentialing onboarding process many months before the provider sees their first patient will ensure they can legally begin, and reimbursement for their services can be timely rendered.

Continual follow-up with the various boards and agencies involved can make the process faster, helping to avoid delays if they didn’t receive everything required but have yet to contact you.

Getting applications accurate the first time and approved as quickly as possible is not always easy. Many practices partner with a medical management service organization (MSO) to alleviate this industry’s infamous headache.

Let Us Handle Your Credentialing for You

At Sullivan Management and Consulting Group, we understand the complexities of owning and operating your own medical practice. Our professionals have been in the industry for over twenty years, and in that time we’ve seen lots of changes to the laws and regulations in this vast industry. With our years of experience assisting physicians just like you, you can now worry less about the tedium of credentialing and focus more on what you love and enjoy, and that’s the practice of medicine and healing your community.

Our credentialing services include:

  • Credentialing for Medicare and Medicaid (CMS)
  • Payor Credentialing/Provider Enrollment
  • Credentialing & Recredentialing w/ ambulatory surgical centers and hospitals
  • Creating & maintaining the Council for Affordable Quality Healthcare (CAQH)
  • Third party administrative (TPA) approvals
  • Workers’ Compensation approvals
  • Obtain current payor contracts and fee schedules
  • Creating & Maintaining NPIs, applicable licenses, and certifications
  • Tracking and storing of continuing education
  • Ensuring a timely and expedited credentialing approval process, including tracking updates

Click here to schedule an appointment to learn what else the Sullivan Management and Consulting Group can do for your practice, or give us a call at 832-323-3691 to discuss your credentialing needs.

author avatar
Brad Petak