Whether you’re a physician starting a practice or a healthcare provider working to expand patient access, getting medical insurance credentialing is vital.
Unfortunately, it’s also a very taxing process. It’s so time-consuming and cumbersome that states like California are considering a bill to simplify the process.
We’ve created a comprehensive guide to take the mystery out of credentialing, offering a step-by-step overview while addressing common pitfalls, requirements, and best practices.
Let’s dive in.
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What is Medical Insurance Credentialing?
The medical insurance credentialing process ensures providers meet specific standards and qualifications set by private insurers, like Medicare or Medicaid, allowing them to bill for services given to patients.
Credentialing often involves verifying a provider’s education, training, work history, background checks, and licenses to ensure they meet the payer’s requirements.
There are credentialing nuances for private insurance versus Medicare. Here’s a brief explanation:
- Credentialing with private insurance is often insurer-specific, meaning each company may require different documents or processes.
- Medicare credentialing guidelines, in contrast, are standardized across the board. Medicare often involves PECOS (Provider Enrollment, Chain, and Ownership System) for enrolling eligible providers.
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Benefits of Proper Credentialing
From the provider’s side, accurate credentialing is crucial to securing reimbursements and building patient trust. How and why is this important? Here’s what’s at stake:
- Expanded Patient Base: Becoming an in-network provider increases your exposure to patients within a given insurer’s network.
- Timely Reimbursements: Proper credentialing ensures insurance companies reimburse claims efficiently, saving your practice time and money.
- Lowers Claim Denials: Without credentialing, you’ll face higher denial rates since insurance payers will require verification of credentials before processing medical claims.
- Boosted Credibility: This process validates that your practice meets the highest professional and ethical standards (essential for new providers).
- Compliance Assurance: Credentialing aligns your practice with Medicare guidelines and private insurance standards, protecting you from legal disputes.
- Reputation: Credentialing improves your reputation, allowing you to treat all patients, regardless of their insurance plans.
5 Key Steps for Insurance Credentialing
The credentialing process may appear, well, pretty intimidating. But breaking it down into bite-sized steps makes it far more attainable.
Here are five valuable steps and tips to help you become a credentialed provider with insurance companies:
Step 1: Get-to-Know Insurance Credentialing Requirements
Start by researching the credentialing requirements of the insurance companies you’re targeting—private insurers and government programs like Medicare. Requirements often include professional licenses, education history, proof of malpractice insurance, and prior work experience.
Next, identify which insurance companies your competitors work with and find open panels for new providers. For reference, some prominent insurance plans for credentialing include Blue Cross Blue Shield, Aetna, Cigna, United Healthcare, Humana, Medicare, and Medicaid.
Step 2: Assemble a Provider Credentialing Checklist
Having a detailed checklist is key for accuracy. A basic provider credentialing checklist should include:
- Curriculum Vitae (CV)
- Current medical license(s)
- DEA registration
- Documentation of Board certification (or alternative pathways)
- Documentation of training (if not Board-certified)
- Proof of malpractice insurance
- Hospital privileges (if applicable)
- Completed application forms (insurer-specific)
- EIN
- Council for Affordable Quality Healthcare (CAQH) number (providers must register with CAQH and submit credentialing information and supporting documentation to CAQH).
Having these documents ready and in one location can help you stay organized.
Other pro tips to follow:
- Send all credentialing information in one packet to avoid delays and confusion.
- Many insurers offer hotlines to assist applicants with credential questions. These resources can save time and take the guesswork out of the process.
- Apply for or update your National Provider Identifier (NPI) during credentialing. This identifier helps track and verify your credentials across different insurance companies.
- Remember to upload a valid W9 and malpractice certificate to the CAQH.
Step 3: Complete Applications, Review, and Submit
Unsure whether to disclose something or provide additional documentation? Do it anyway. Incomplete applications are one of the biggest speed bumps in the credentialing process.
If possible, save and print a copy of your completed application for your records before you submit it to the organization.
Next, submit applications directly to insurance companies or leverage credentialing services for physicians (more on this later). Organizations like CAQH make it easier to streamline standard documentation.
Step 4: Follow Up with Payers
Depending on the complexity, insurance credentialing can take several weeks to a few months. Ensure you stay in touch with payers and follow up if there are delays or requests for additional information.
Step 5: Create a System for Ongoing Maintenance
Once approved, it’s crucial to maintain compliance by keeping records up to date. What does this mean? Be consistent when renewing licenses, certifications, and other credentials to stay eligible for reimbursements.
Common Credentialing Mistakes to Avoid
Some common credentialing errors can derail your progress, costing you time, revenue, or both. Here’s what to watch out for:
- Incomplete applications: Missing signatures, forms, or documents can lead to rejection or long delays.
- Neglecting timelines: Each insurer has specific deadlines, so failure to follow up can mean starting the process over.
- Not reviewing Medicare guidelines: Overlooking Medicare’s strict rules can result in penalties or reimbursement denials.
- Failing to track renewals: Credentialing is an ongoing process requiring regular updates.
- Outdated processes and systems: Look for issues and areas where technology can improve workflows. Common errors in records include outdated accreditation from the CAQH or incorrect information and taxonomy codes on provider W-9 profiles.
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Additional FAQs to Get You Started
What are credentialing services for physicians?
Many healthcare providers choose to outsource credentialing to companies specializing in this area.
Credentialing services, also called Credentialing Verification Organizations (CVOs), help with everything from insurance billing, payment procedures, and verifying documents to submitting applications and following up with insurers.
They can also help providers maximize their participation in insurance networks while avoiding delays in credentialing and rising healthcare costs during the process. These services save time and money and reduce errors, ensuring you focus on providing patient care.
Questions to ask a credentialing service:
- Do they have experience negotiating insurer credentialing requirements such as premium quotes?
- What is their record of successfully negotiating good credentialing results on their customers’ behalf?
- How does the company handle inconsistencies and problems with insurance companies?
How long does the credentialing process take?
Typically, the credentialing process with insurance companies takes 90 to 120 days. Medicare and Medicaid usually take 40 to 60 days, but it can take as little as 15 days or as long as 3 months.
But this timeframe can vary, as some payors may complete it quicker, and others may take longer, especially for those with specialty practices.
As for the actual credentialing application, expect to spend 2 to 6 hours on each application. The estimated time commitment for each panel application can be 10 hours or longer.
If you plan to practice before you receive your credentials, you can request a statement of supervision. This action allows providers to temporarily bill under a supervising physician until the credentialing process is finished.
What about renewal? Do I need to renew my practice’s insurance credentials?
Yes, you’ll need to renew the insurance credentials for your practice. However, the frequency depends on the company. Some require renewals every 12 months, others up to every 3 years. Luckily, there are companies you can hire and software programs you can use to manage credential processes.
You’re Credentialed – Now What?
Proper medical insurance credentialing isn’t just a mandatory task—it’s an investment in the success of your healthcare practice. By understanding how to get credentialed with insurance companies, you set up your practice to grow sustainably.
What’s next?
Once credentialing is complete, ensure your billing system is updated with payer information and start submitting claims. At this point, advanced medical billing software will make all the difference.
CollaborateMD offers cloud-based medical billing software that can help providers:
- Simplify billing processes
- Avoid complicated workflows
- Streamline revenue cycle management with transparent reporting tools.
- Manage patient notes, billing codes, and rounding lists with features like Charge Capture.
- Optimize revenue cycles, speed up payments, and minimize claim errors with Electronic Remittance Advice (ERA)
Contact CollaborateMD to learn more about how your practice can automate the billing process, boost revenue, and optimize your payment collection. Your future self (and your practice) will thank you.
