Frequently Asked Questions on Credentialing
By: Crissy Spearman So you’ve decided to open your Medical Practice, or perhaps you’re expanding your business to include a new location and more physicians. In all the excitement, paperwork, and planning, one very important thing that you cannot afford to overlook is credentialing. What is Credentialing? In fancy language, credentialing is the process of establishing the qualifications of licensed professionals. In simpler terms, credentialing equates to being able to accept different forms of insurance at your Medical Practice. Insurance companies and healthcare agencies use credentialing to ensure all practitioners meet their necessary requirements and are truly qualified. Unfortunately, every organization’s credentialing process is a little different. For this reason, you need to contact each organization or agency you want to be credentialed with and ask them their specific requirements for getting credentialed. You should also inquire if there are any fees associated with each credentialing application you submit. What Documentation is Required for Credentialing? Malpractice NPI number State Issued License Board Certificate Curriculum Vitae (CV) X-Ray Certs/CLIA Certs (if those services are provided) How Long Does Credentialing Take? The short answer – a long time! Credentialing can take anywhere from three months to more than a year. Several factors influence the length of time it takes, including if you submit your application electronically or by mail and if there are any errors or if paperwork is sent back for any reason. Why Should I Get Credentialed? Getting credentialed may lead to higher reimbursements or being listed as a preferred provider in an insurance directory. Some insurance companies will not pay you at all if you are not credentialed. What is Facility Credentialing? Some organizations will credential both your Medical Practice facility and your providers. Facility credentialing ensures your facility meets the requirements of the organization credentialing you. Are There Tips for Medicare Credentialing? For Medicare credentialing it is in your best interest to credential electronically through the PECOS system. This will require you to have the NPI login for the provider. If you do not have the login information, you may call the National Plan and Provider Enumeration System (NPPES) and they will reset the password for the physician. You can also submit a paper application, but it can take up to 120 days just for your paper application to be looked at. By using the PECOS system, you cut that time to 20 days. What is CAQH? The Council for Affordable Quality Healthcare (CAQH) is a website used by many insurance companies for credentialing. This site is designed to help minimize the amount of paperwork associated with your application process. By logging on to www.caqh.org, you can fill out all the necessary information and save it. Then you can give certain insurances permission to access your information for credentialing purposes. What is Re-Credentialing? Each healthcare organization you are credentialed with will periodically have you re-credential. This occurs at timeframes set by each individual organization and involves verifying that all of your information is still the same or submitting any updates. LIKE THIS ARTICLE? Click here to register for your complimentary subscription to Medical Practice Success. In addition to getting the latest article every Tuesday morning in your inbox, you'll also be given a free copy of our e-book The Five Mistakes Medical Practice Owners Make, and What You Can Do to Avoid Them.
