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Five Keys to Effective Credentialing

Credentialing can be burdensome, time-consuming and tedious. Details matter. Expertise and follow-up are critical to proper enrollment and protecting cash flow. In this article we provide five keys to effective credentialing.

1. Begin the Process Early

Some commercial insurance credentialing processes can take up to 120 days to complete. Start compiling all the necessary information as soon as you can to protect against potential delays and unpaid claims.

2. Attention to Details Matters

Because credentialing is intimately connected to cash flow, make sure all necessary information is complete and accurate. Missing or incomplete information will delay the process. Some of the most common errors or omissions may include:

Incomplete Provider Work History – Include current and all prior professional work history since graduating medical school. Work history must include MM/YYYY format on all start/end dates.

Malpractice Insurance – Include the current policy and up to 10 years policy history. It’s also recommended to include the past 10 years malpractice claim history.

Hospital Privileges – Providers must have admitting privileges to an in-network hospital to participate with a health plan. If that doesn’t exist, then another in-network physician will need to supply in writing an admitting arrangement attesting that he/she will agree to admit any patients on the provider’s behalf. Also, a list where the covering physician has privileges will be needed.

Covering Colleagues – Providers are responsible for providing coverage for patients 24/7 and will need to disclose which colleagues may provide coverage during times of absence. This is particularly important for solo practitioners.

Attestations – Fully answer all yes/no questions on each application and provide complete details for response when necessary

3. Stay Current With CAQH

A current CAQH profile is an important part of some state Medicaid plans. Make certain that a provider’s CAQH profile is current with all personal details, attestations, and signed attestation page. An incomplete profile will cause delays in the process. CAQH must be attested for insurance plans to be able to view it.

4. Include the Provider during the Process

Providers are responsible for completing the credentialing process for all the payers with which your organization participates. Although burdensome, it is critical that the provider assist throughout the process and provide all necessary credentialing data points.

5. Know Your Key Payers

Know which payers represent key revenue sources to your business so that you can prioritize credentialing processes accordingly. You can selectively schedule patients for your new provider based on which plans have been completed until the new provider is fully credentialed with all networks and plans.

Credentialing doesn’t have to be a burden. Contact us today to explore how Dean Dorton Healthcare Solutions can help simplify your credentialing.