For a lot of practitioners, credentialing is a necessary evil when joining a practice or a hospital’s medical staff. It’s also part of becoming networked with insurance companies. When done well, credentialing stays invisible to practices and patients alike. Done poorly, it can disrupt patient scheduling and cause delays in cash flow as insurers and office staff hunt down missing or erroneous information.
Although payers, healthcare organizations, and some states have specific requirements for physician credentialing and enrollment, there are best practices that apply regardless of the administrative or regulatory terrain:

  1. Build time into the process. How long should it take to credential a physician? Every payer’s timeline for processing applications is different, and the payer landscape changes with every merger.
  2. Check your work. A new provider can be credentialed within 90 days, for most payers, but incomplete or outdated information can stop the credentialing process in its tracks. And that occurs far too frequently.
  3. Master CAQH requirements. Most payers have adopted the Coalition for Affordable Quality Healthcare (CAQH)’s uniform credentialing program. Practitioners who routinely update and attest with CAQH find credentialing and re-credentialing much easier.
  4. Get to know your state laws. States may or may not have laws for timely credentialing, credentialing in multiple states, physicians moving from one practice to another within the same state, or telemedicine. The Federation of State Medical Boards (FSMB) or state chapter of theMedical Group Management Association (MGMA) can help ensure you’re following appropriate state standards.

Another way to speed things along is to link a physician’s start date to his or her submission of the necessary credentialing paperwork. Contracts that require linkage are becoming more widespread, although they are not popular with physicians. If you opt for contracts with a linkage requirement, specify that the effective date may be no sooner than 120 days after receipt of all information. This enables the new physician to fill his or her schedule sooner and grow the practice faster.
Using practice software with a specialized credentialing module or reminders of important dates (for reappointment to the medical staff, insurance plan re-enrollment, etc.) can also help keep the credentialing process flowing smoothly. Now more than ever, “clean” data—for providers, payers, and patients—is vital to provide efficient care.
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Last Updated on April 15, 2016