If you operate a healthcare practice, you are likely well-acquainted with the various components of the healthcare system and its processes. Some of these components occur rapidly, while others may take longer to develop. Credentialing represents a vital and important phase in the onboarding procedure for healthcare professionals. This process is also referred to as provider credentialing, medical credentialing, and physician credentialing. It entails a thorough verification of healthcare providers to confirm that they fulfill the necessary criteria for delivering quality services. However, it is important to note that this process can be quite time-consuming and may require more time than healthcare providers typically anticipate. If you are interested in understanding the duration of the credentialing process and the primary factors that may cause delays in provider credentialing, we encourage you to read this article. Additionally, you will discover effective strategies to enhance the efficiency of the credentialing process. Let us begin!
What is the typical duration required to credential a provider?
Physician credentialing provides numerous advantages for both patients and healthcare providers. This process ensures that all professional credentials are accurately verified, allowing patients to receive high-quality care. Credentialing specialists are also capable of identifying fraudulent credentials, thereby preserving the integrity of a healthcare practice. Furthermore, a more expedited credentialing process enables patients to access the quality care they desire without unnecessary delays. Ultimately, this efficiency allows healthcare providers to receive their reimbursements promptly.
Typically, the entire procedure can take several weeks to months to finalize the credentials for healthcare providers. Typically, the duration for provider credentials averages between 90 and 120 days. However, it is important to note that this is merely an average estimate. The precise duration of a provider’s credential is contingent upon several factors, including:
- The efficiency of the organization’s credentialing process
- The accuracy and effectiveness of provider documentation
- The complexity of the provider’s background
- The method of credential
Generally, the anticipated approval times for credentials are as follows:
Credentialing for Medicare and Medicaid: 60 to 90 days
NPI application: 30 minutes
Initial versus re-credentialing times: 90 to 150 days / 45 to 90 days
Commercial insurance carrier credentialing: 60 to 90 days (30 days for contracting)
Online CAQH application: 3 hours
The provider credentialing process should ideally be expedited. If healthcare providers are solely focused on credentials, they may neglect their patients. This can adversely affect the revenue stream of a healthcare organization. If healthcare providers do not meet the credentialing requirements for approval, they will be unable to offer their services. Consequently, the healthcare organization will miss out on the benefits of its professional expertise. Therefore, the medical credentialing process must be efficient and effective, enabling healthcare providers to reach their objectives.
What documents are necessary for Credentialing?
The initial phase of credentialing healthcare providers entails the verification of all documents submitted by these providers. Credentials specialists are tasked with this responsibility and meticulously review each document. They also conduct primary source verification to ensure accurate assessment. During this initial phase, the following documents are verified as they are crucial for the credentials process.
Application
The initial application serves as a form that collects all pertinent information, including personal details such as contact information and other background specifics. The processing time for credentialing applications can vary.
Education
Providers must submit documentation of their educational qualifications, including certificates, diplomas, and similar credentials.
Personal identification
This category includes the passport, driver’s license, and social security number.
Professional documents
This encompasses board certificates, medical licenses, and associated registrations, among others.
Previous work history
Providers are also required to furnish details regarding their past responsibilities, including affiliations with professional organizations, employment dates, and job descriptions.
Malpractice insurance
Alongside the documents, providers are required to submit proof of malpractice insurance coverage.
DEA registration
If healthcare providers prescribe controlled substances, they must submit their registration details to the Drug Enforcement Administration (DEA).
Criminal record
Credential professionals also investigate whether there is any criminal record associated with a provider to avert potential issues in the future.
What are the primary steps involved in the credentialing of providers?
The primary steps in the credential process are outlined as follows:
Information Gathering
The initial step entails the collection of the necessary credentials for credential. Comprehensive information regarding healthcare providers is compiled. Additionally, other pertinent details include the physical address, mailing address, individual or group National Provider Identifier (NPI), clinic fax number, Tax Identification Number, Master Provider Index, and so forth. The duration of this step can vary, but it typically spans a few weeks.
Creation of a Payer List
The subsequent step involves formulating a list of payers and insurance networks with which you intend to contract or participate in their insurance plans. The choice of insurance networks is determined by the preferences and requirements of the healthcare practice.
Government Health Plans
This includes TRICARE, Medicaid, Medicare, the Children’s Health Insurance Program (CHIP), and VA Health Care.
Health Insurance
- Right Health
- United Healthcare
- Cigna
- Humana
- Anthem
- Kaiser Permanente
- Blue Cross Blue Shield
- Bright Health
- Aetna
- Oscar Health
- Sidecar Health
- Lemonade
Development of CAQH Profile
The CAQH (Council for Affordable Quality Healthcare) is a database that authenticates provider information. Initially, a CAQH profile is established and subsequently maintained. Creating a CAQH profile is highly advantageous as it enables one to apply for credentials at multiple organizations simultaneously.
State credentialing application
Some credential applications are specific to states and gather information related to education, training, experience, and licensure.
Determining the payer’s credentialing requirements
The initial step you should undertake before commencing your application process is to ascertain how many payers you wish to collaborate with. Additionally, you should identify the requirements of each payer. By accessing their official website, you can ascertain all specific requirements. Subsequently, you can submit your application accurately.
Submission of application
Once you have compiled a list of payers and identified their requirements, you may proceed to submit your application to each payer. It is generally advisable to initiate your process with government insurance, as it typically requires more time compared to other programs.
Regular follow-ups
Following the submission of your application, it will undergo an approval process. This phase of approval could extend over several weeks to months. To expedite the process, experts recommend making regular follow-ups with payers. In the absence of follow-ups, delays in processing time may occur.
What elements can influence the duration of provider credentialing?
A variety of factors can affect the length of the credentials process, including:
Primary source verification
Since credentials must be thoroughly verified against primary sources for every detail, this process can be time-consuming. Credentials experts are required to communicate with educational institutions, previous professional organizations, licensing boards, etc., to verify the credentials of healthcare providers.
Red Flags
During the verification of primary sources, if any red flags or issues are identified, experts will take steps to thoroughly investigate them. This process, however, consumes valuable time.
Documentation Issues
The absence of any document or the presence of incorrect information can also lead to delays in the process. Consequently, regular follow-ups are conducted to mitigate this issue.
Number of Payers
When healthcare providers apply to multiple payers, the process will take longer since each payer has distinct requirements. Therefore, healthcare providers must analyze these requirements and devise plans accordingly.
Efficiency of Payers
The efficiency of payers significantly influences the duration of the credentialing process. If a payer is efficient in handling credentials, the timeline for medical credentials can be considerably shortened.
Application Type
The nature of the application is also associated with the duration of credentials. When the credentials process is conducted electronically, it tends to be faster compared to paper applications.
Response Time to Requests
In many instances, payers request additional information during the credentials process. Timely provision of this information can expedite the credentials process.
Individual or Group Credentialing
Individual credentials are generally quicker and take less time than group credentialing.
Self-Credentialing or Professional Credentialing
Healthcare providers have the option to choose between self-credentials and professional credentialing. Professional credentials are typically more efficient and comprehensive compared to self-credentials.
Follow-Up Frequency
If experts do not conduct regular follow-ups, they may fail to identify arising issues, which ultimately impacts the speed of the process.
What are the most effective methods to minimize the duration required for credentialing a provider?
By implementing the following strategies, you can enhance the efficiency of provider credentialing and yield numerous advantages for your healthcare practice:
Initiate the process sooner.
Do not postpone until you believe the provider is ready to begin. Take proactive steps to apply as early as possible. By commencing the credentials process ahead of time, you can safeguard your practice against potential errors or complications that may arise during the credentials process.
Simplified document submission
Credentialing software allows providers to easily submit their applications via the internet. This ensures that their information remains secure, and the credentials process is expedited without unnecessary delays.
Adhere to a defined process.
It is essential to establish a workflow tailored to your organization. This will undoubtedly mitigate errors that could hinder the efficiency of your credentialing process. Credentials professionals consistently ensure that each step is executed promptly and that no step is neglected.
Utilize digital methods for data storage.
Employ digital solutions to store and monitor all documents pertaining to provider and payer information and communications. When contacting payers, ensure that you document the call reference number. This will assist you in recalling details should any issues arise.
Establish reminders and notifications.
Follow-ups are essential in the credentialing process. Consequently, it is advisable to set reminders and specific notifications for follow-ups, as well as to implement any necessary adjustments.
Select any credentialing service.
To accelerate the credentialing process, you may opt for any credentials service. This choice will enable you to achieve a quicker, dependable, and results-driven credentials experience for healthcare providers.
Provide professional assistance for Provider Credentialing.
If you are concerned about the safety and improved outcomes of your healthcare practice, it is imperative to concentrate on your provider credentials process. Healthcare providers must undergo all necessary checks to ensure the delivery of the highest quality care. Should you encounter challenges in the credentials process and seek a premier credentials service, MedEx MBS stands as your partner in excellence. We offer efficient credentialing services across medical, behavioral, and dental healthcare practices. By employing our healthcare provider credentials services, you can ensure oversight of the credentials process and observe the development and prosperity of your healthcare practice. Therefore, do not hesitate to arrange a consultation with our credentials experts and optimize your credential process today.