A Guide to Provider Credentialing 2021 | Credentialing Checklist

Credentialing dates back to as early as 1000 BC when the ancient Persian cult of Zoraster developed a process for 'licensure' of physicians. 

An applicant needed to prove they successfully treated at least three heretics before gaining the right to practice medicine. If all three survived, they were deemed qualified to practice medicine 'forever and ever.' 

Alternatively, if all three die, they may not practice medicine. 

Today, the process of provider credentialing has changed significantly. Still, the goal remains the same - to assess the knowledge, skills, and experience of a provider before placing them into an environment where harm to others may result.

In this article, we will discuss provider credentialing and answer questions you may have regarding the process. We will also discuss what the future may hold for credentialing.

What is Provider Credentialing?

Provider credentialing is a multi-process approach for verifying, appraising, and certifying a provider's potential ability to provide safe, high-quality healthcare services within an organization. 

It is a process of verification, appraisal, and certification used to verify a provider's competency and suitability for entry into a specific organized health environment. The procedure also involves checking for criminal records, sanctions, among other things. 

Private and public payers, such as managed care and insurance companies, perform provider credentialing, sometimes independently and sometimes in conjunction with hospitals or healthcare systems, through credentialing verification organizations (CVOs).

How does Provider Credentialing Work?

The credentialing process of providers is done in phases by either the credentials department of the provider organization, the payer or a credentialing organization contracted by the provider organization.

• The process involves:
• Collecting information from the provider
• Primary source verification (PSV) of the provider's data
• Assessment of all info
• Recommendation 

As part of collecting a provider's information, obtaining all the certifications and documentation is necessary. Following this, the data is verified for accuracy and legitimacy. 

In general, the specific data and documents collected are relatively uniform, although they may differ depending on which regulatory and accreditation body/bodies the organization subscribes to. 

These agencies may include The Joint Commission (TJC), Centers for Medicare & Medicaid Services, The National Committee for Quality Assurance, individual state oversight bodies, the National Association for Healthcare Quality, DNV-GL, the Utilization Review Accreditation Commission, among others. 

Primary Source Verification

Finding the authentic source of data or documents is crucial in avoiding bias, inaccuracy, or unreliability in secondary sources of information. 

Thanks to today's technology, healthcare providers or impostors can conveniently fabricate or exaggerate their qualifications to gain patient access. 

Thus, PSV is a crucial stage in credentialing. Poor credentialing can lead to serious patient harm or death, in addition to millions of dollars in negligent credentialing lawsuits. A typical PSV procedure involves:

• Validating that the provider holds a government-issued identification card, a criminal background check, and an OIG clearance
• Reviewing the provider's education, residency, fellowship, primary source training, and other credentials
• Reviewing state licenses, controlled substance registrations, and DEA records
• Reviewing applications (including privilege requests, if any)
• If applicable, validating the provider's status as a board-certified provider.
• Checking coverage and history of claims for professional liability
• Verifying a provider's past work experience
• Reviewing application requirements such as death master lists, board certifications, etc. for the /health plan
• Acquiring and verifying references (such as the program director and department chair)
• Obtaining the verifications required by NCQA, TJC, or URAC, such as training and education, licensing, malpractice history
• Verifying the primary source verification requirements in each state.

The Benefits of Provider Credentialing

For practices seeking to become credentialed and favored by insurance companies, provider credentialing holds several advantages. 

In the healthcare industry, the credentialing process provides quality assurance. It helps ensure healthcare standards are consistently met throughout the medical community and ensures patients receive the best possible care. Insurance companies tend to favor medical physicians and practices that are proven to be competent to perform their specialties to keep costs down.

Medical practices can also avoid losing thousands of dollars in revenue by avoiding delays or denials of reimbursements. Insurance payers may not reimburse medical facilities for their treatments if they fail to obtain proper credentialing. Medical practices that permit physicians to practice before or during credentialing processes may backdate reimbursements to cover the services provided.

Furthermore, credentialing ensures that clinicians and practices have the experience and skills necessary to perform medical procedures on patients. All the background knowledge credentialing provides helps restore trust between patients and healthcare providers, reducing the risk of medical errors. They can place their complete faith in their physicians with the knowledge they are qualified and merited to be their providers. 

How Often Should Provider Credentialing Occur?

At least every three years, healthcare providers need to renew their credentials. Some healthcare facilities or insurance companies re-credential more frequently than others.

What Can Delay a Provider's Credentialing?

At least two reasons can delay provider credentialing:

Poor planning

It is not uncommon for newly graduated doctors to wait until they arrive in town before applying for credentials, even though they could have started the process weeks earlier. Referees may also delay the process by several weeks or even months, as their responses can take up to a year. 

A credentialing application is not complete until an MCO has received all references - and credentialing cannot proceed until all referrals have arrived.

NCQA standard

Several points must be validated, such as settlement records for professional liability, before credentials are approved, as per the NCQA "Primary Source Verification" standard. As a result, an MCO may withhold credentials from a newly hired physician until the last detail is verified.

How Soon Should a Provider Begin the Credentialing Process?

Most health care organizations recommend applying 90 days before a practitioner's start date. The benchmark of 90 days allows extra time if verification sources fail to respond promptly or if discrepancies need to be clarified. In addition, all the approval committees will be able to access the provider's file. 

Provider Credentialing 2021: What Has Changed?

Technology, health care integration, and increasing expectations of a high level of customer service (patients and providers) are transforming credentialing in the following ways:

• The credentialing process is going paperless
• More and more users rely on credentialing data for their authentication
• Cloud technology allows for remote credentialing

Practice Documentation Checklist

Adding Providers to New Practice

This checklist is for you if you are starting up a new practice, and are attending to guarantee that each one of your providers has followed the credentialing process properly.

Step by Step

1. Build a new group in your state, and acquire your Tax ID information from the IRS.
2. Download the e-file (CP-575) when getting the data on your EIN.
3. Give the address where your practice is located. Since you are already established as a private medical practice, this data will be easy to achieve.
4. Upon performing the previous steps, you can then apply for a Group NPI.
5. Next, be sure to update your attested CAQH profile with your CAQH ID.
6. Identify the payers you’re seeing to credential with, including commercial PPOs or HMOs, Medicare, Medicaid, Worker’s Compensation, Tricare, or any other payers about you that you may encounter at your practice.
7. Develop a W9 form with your billing address.
8. Since hospital credentialing will be needed for many specialist services and will be asked by insurance providers for credentialing, guarantee that the credentialing process is in growth with local hospitals or have a covering provider or hospitalist group adjusted for hospital admissions.
9. Provide a permanent office phone and fax number to be held on your CAQH and other applications.
10. Develop a malpractice policy, as this is a must for most insurance companies.
11. As you’re updating your CAQH, be sure to allow access to your profile for relevant insurance companies.
12. If you’re looking to apply with Medicaid, you will need a business license, articles of incorporation, group/practice mortgage insurance and worker’s compensation insurance, CLIA certification or waiver if applicable.
13. Once all of these steps are in position, you will be capable to submit letters of interest or applications to payers.

Practice Documentation Checklist

• CP575 OR 147C Letter
• Approved and completed W9 form
• Business license
• (If needed in your state) Fictitious name permit
• Articles of incorporation or organization
• Liability insurance coverage
• Worker’s compensation insurance coverage
• CLIA certification or waiver
• EFT verification from your bank or a voided check

Provider Documentation Checklist

• Professional license
• DEA certification
• CDS certification
• Board certification or proof of eligibility
• PLI certification
• Professional school diploma
• Certification of completion for internships, fellowships, or residencies
• CAQH login and password
• PECOS login and password
• State Medicaid login and password
• Availity system login, password, and backup codes
• Current CV with exact beginning and ending dates
• Hospital admitting privileges or covering provider
  

Adding a New Provider to a Current Practice

This checklist is for you if you are now running a medical practice and are just looking to add a new provider to your current team.

Step by Step

1. Give an updated and attested CAQH profile, with new practice association (including start date) posted. Additionally, the provider’s license and DEA must also be updated with the new state they’ll be operating in if this is different from their primary affiliation.
2. The group the provider will be joined to will require to supplement a list of payers they are currently affiliated with, including commercial, Medicare Advantage, Medicaid HMOs, worker’s compensation, Tricare, as well as any TPAs.
3. Supply Tax ID to insurance organizations and update your CAQH profile with this data.
4. As hospital credentialing is required for some insurance payers or practice providers, the list of hospitals you plan to have privileges with will require to be updated in your CAQH profile. If you don’t plan on having hospital opportunities for your practice, you will require to build an admitting system with a provider or choose which hospitalist or ER in your area you will be using for admitting orders.
5. Provide new or updated malpractice policy and update in your CAQH profile.
6. Provide the group’s first billing model, which will be listed on applications with a Tax ID.
7. Provide the group’s Medicare PTAN that you intend to be included on, which will be listed on your Medicare application connected to the new group.

Provider Addition Documentation Checklist

• Professional state license
• DEA certification or covering provider name
• CDS certification
• Board certification or proof of eligibility
• PLI certification
• Professional school diploma
• Certificates of completion for internships, fellowships, or residencies
• CAQH login and password
• PECOS login and password
• State Medicaid login and password
• Availity login, password, and backup codes
• Current CV with exact beginning and ending dates
• Hospital admitting privileges or covering provider

Conclusion

The goal of all health institutions is to maintain the best quality of care for their patients. Complications can arise when medical providers are not qualified to perform their duties. With credentialing, hospitals and other healthcare facilities can be confident that the medical providers they hire possess skills, expertise, records, and other credentials necessary to provide competent care.

Today, the credentialing process is more efficient. A significant number of healthcare institutions are moving away from paper-based processes and digitizing their credentialing. This ensures minor errors in gathering providers' information and fewer administrative expenses. In addition, cloud storage allows for easy access to view and edit records.

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