How to Simplify Physician Credentialing

August 18, 2015 by Antonio Arias, MBA, CHBME

Topics: Medical Billing, Revenue Cycle Management, Practice Management

If credentialing a new physician is on your healthcare practice’s to-do list, it’s probably the line item you’re dreading the most. There’s not a medical professional among us who wouldn’t describe the physician credentialing process as tedious, time-consuming, and burdensome – the kind of onerous medical practice task that feels like it sucks up far more office energy than it should.

What is Physician Credentialing?

Physician credentialing is the process used by payers to evaluate the qualifications and practice history of a doctor or other practitioner. Credentialing requires physicians to verify their education, training, residency, licenses, malpractice coverage, clinical judgment, and any certifications related to their specialties. The process that involves data collection, source verification, and committee review. For many healthcare practices and medical professionals alike, the physician credentialing process is just as arduous as it sounds.

But it’s also extremely important for both parties involved (payer and provider). Not only does it ensure patient safety, but it also paves the way for practices to enjoy proper reimbursements and on-time payments from their contracted third-party payers. Ultimately, credentialing is a necessary evil on the road to medical practice income – so it’s crucial for you to approach it with a positive mindset and a strategy for success.

10 Easy Tips for Simplifying Physician Credentialing

1. Don’t Delay

In a best-case scenario, credentialing can be completed in about 90 days. Worst case: double that. Don’t procrastinate when it comes to getting the process started! As soon as you know you’re bringing a new doc aboard, estimate a 120-150 day window for getting all credentialing completed – and try to beat it. 

2. Utilize Technology

Leveraging available technology can significantly streamline the credentialing process and reduce human errors in the process. There are a variety of credentialing software platforms that healthcare practices can utilize to improve efficiency and take much of the hassle out of the physician credentialing process.

3. Get the Doc’s Commitment

When a new physician joins a medical practice, having a series of hard deadlines related to the medical credentialing process can ensure that everyone stays on track with getting all the necessary paperwork completed before the physician has the opportunity to see a patient. Some large healthcare organizations will tie a new physician’s start date to his or her submittal of all credentialing paperwork – say, no sooner than 120 days from receipt of all required information. Consider whether that’s right for your practice's revenue cycle management.

4. Update CVs

Ensuring that a physician’s curriculum vitae (CV) is fully updated to reflect their current status can avoid any confusion throughout the physician credentialing process. In addition to obvious details like education and work history, an updated CV should also include privileged facilities, contract groups, and any leadership or teaching positions they might hold. It’s also a good idea to conduct a quick background check to verify that everything on a physician’s CV is accurate.

5. Plan Smart

Since credentialing is such an onerous process, it’s important to try to do as little duplicate work as possible. Figure out how to use the opportunity to your advantage. Do two payers have identical applications? Are there state-to-state “reciprocity regulations” you can leverage? (If a physician is already credentialed by Anthem in one state, for example, it will be easier for them to get credentialed in another.) Or, can you use the information you’re collecting to complete any other necessary registrations for the new physician? Find out.

6. Digitize Everything

Making all supporting documents necessary for credentialing accessible electronically can greatly streamline the process. If a missing document is requested at the last minute, having an electronic copy readily available can eliminate a mad scramble to track down the physical document and sort out how to deliver it to where it needs to be (via fax, mail, scanning, etc).

7. Verify State Regulations

Laws regarding medical credentialing vary from state to state and can be impacted by new legislation. Just because you navigated the credentialing process easily two years ago doesn’t mean the same requirements will be in place next year. It’s important to check for updates and changes every year and update internal processes accordingly to avoid any unpleasant surprises along the way. 

8. Check Every Box

Be sure to go through each payer’s application closely and supply all required information; an Anthem rep has said publicly that as many as 85 percent of credentialing applications are missing critical details required for processing. The only way to meet the optimal 90-day credentialing time is to get each application right the first time. 

9. Secure Additional References

Most credentialing organizations require the submission to include three professional references. In many cases, the actual review doesn’t even begin until all required materials are received. That means if a single reference is delivered late, the entire credentialing process can be delayed. By securing additional references (perhaps four or even five), the odds are good that everything will stay on track.

10. Utilize CAQH

The Coalition for Affordable Quality Healthcare (CAQH) has a uniform credentialing program, and physicians who regularly update and attest with CAQH find credentialing and re-credentialing much easier. Encourage your providers to stay up to date and, as you pursue new hires down the road, ask candidates about CAQH to know if their diligence could keep less work off your plate in the onboarding process.

Credentialing physicians may often feel like an inconvenience, but it is an important part of the healthcare system. Taking the time to set up a thorough system for filing a physician credentialing application will reduce unnecessary delays and avoid costly mistakes. Faster, more efficient credentialing means your healthcare practice’s new physicians will be able to treat patients sooner, providing a boost to your revenue.

Are you interested in learning more medical billing tips? Visit our blog! 

...and if you need help with your practice revenue...


Subscribe to Our Blog

Stay in-the-know on trends, best practices, and news affecting the medical billing industry!