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by Antonio Arias, MBA, CHBME

How to Simplify Physician Credentialing


If credentialing a new physician is on your 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 way more office energy than it should.

For the uninitiated: 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… and yeah, it’s as bad as it sounds.

But it’s also extremely important for both parties involved (payer and provider). Not only does it ensure patient safety, it 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 toapproach it with a positive mindset and a strategy for success.

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. 

Get the Doc’s Commitment: 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.

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.

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. 

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.

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

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by Antonio Arias, MBA, CHBME

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