The primary purpose of provider credentialing is to ensure that healthcare providers have the required training and experience to provide the highest level of care to patients. But often undertaking the entire process in-house can be high-risk and overwhelming to staff. What can providers do to improve verification and validation of professional's qualifications?
When your facility hires a new healthcare provider, it’s pivotal to move them through the medical credentialing process. Even if a healthcare provider has been approved by payors in the past, they need to reapply each time they begin work with a new employer. How can you make sure to execute provider credentialing efficiently?
Before you start, it is important to note that each insurer requires different documentation and even a single piece of missing information can set the process back by weeks or months.
The list of documents required normally include:
While most of this information is generally available from the provider’s resume, your practice must take steps needed to ensure accuracy for provider credentialing.
Several healthcare insurers require practices to apply for credentialing through the Council for Affordable Quality Healthcare (CAQH) parallel to completing their individual applications.
Now that you have completed all the necessary steps, you’ll need to wait for approval. Ideally this should take 90 to 150 days though sometimes it can be as long as 6 months. Susan Ward, the director of payor enrollment at Simply, explains that the process becomes complicated in part because each state has specific provider credentialing laws and regulations.
The provider credentialing process is an ongoing one and does not end with approval, meaning continuous work for the staff at your practice.
Provider credentialing is one of the most significant compliance issues due to its prominent impact on revenue and credibility, along with the myriad steps associated with the process. Doing it in-house requires extensive time and attention. The slightest lapse could result in problems at multiple levels. Here are some of the most common problems faced by practices that are trying to juggle the precarious task of credentialing.
It is becoming increasingly challenging to identify, retain, and train qualified staff to complete initial and continuous credentialing. Provider credentialing is one of the most labor-intensive areas in the healthcare industry and is the most important step to any organization’s success.
A major challenge is collecting, assessing, and maintaining a huge volume of data. Organizations that continue to manually process their data can have up to an 85% error rate due to human errors and oversights. Seemingly trivial information such as dates, names, and locations can be incorrect or missing, leading to delays in processing and payments.
The efficacy of the process depends on various contingencies such as accuracy and timing, resulting in inevitable delays in payment. When done manually the process is even more drawn out and leads to interruptions in revenue. This in turn is detrimental to the financial health of your practice.
Practices that are unable to keep up with ever-changing compliance requirements are vulnerable to unexpected fines and penalties. Since provider credentialing is not a one-time process that can be forgotten after approval, it demands the constant attention of an individual focused solely on it.
Organizations must make sure that all information regarding prospective candidates and applicants is private, confidential, and secure. If information is leaked, the organization can be subject to hefty fines and sanctions. Outsourcing this process can simplify the process and leave you more secure.
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