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Medical Credentialing Tips and Best Practices

August 24th, 2017 - By Matt Garnese

Are you, or is anyone you know, starting a medical practice? One of the most important first steps in creating a financially stable practice is completing your provider enrollment, becoming affiliated with insurance companies in order to receive reimbursement for medical services.

Medical Credentialing is a process whereby insurance networks check to make sure that the provider meets the standards set out by the insurance company. In this process, they review a range of documents including medical licenses, malpractice insurance, schooling information, and background checks. Credentialing is performed on an individual state-to-state basis.

In a recent webinar, titled “The Dos & Don’ts of Medical Credentialing”, our Credentialing executive team discussed best practices and what to avoid when getting your practice credentialed.

What to Focus on in Medical Credentialing

  • Get credentialed early on: Timeframes vary from three to six months, depending on payer and location. For example, at the beginning of the year, more doctors submit applications, and due to that influx credentialing can take up to five months. It’s important to be aware that this waiting time can affect your practice so get an early start.
  • Make sure to keep all your documents up to date: Make sure your CAQH, DEA, License, Malpractice Insurance, etc. are always organized, accessible, and up to date. Malpractice expires annually, for example, so making sure it’s up to date will help you in the process.
  • Be aware of the credentialing requirements in your state: This is especially if you are starting a practice in a new area. Requirements vary from state to state, and each insurer has a different set of regulations. Also expect to receive additional fees, particularly from DMERC, Medicare, and Medicaid.

What to Avoid When Credentialing Your Practice

  • Don’t neglect to check in early and often: Insurance networks can sometimes make mistakes. You want to remain on top of the process, so always follow up after making a submission.
  • Don’t wait until the last minute: Add providers to your plans and to notify insurance companies of any changes (such as your practice’s address). Always update your documents well before submission.
  • Don’t forget to revalidate and re-credential: Failure to re-credential can prevent you from receiving third party payments, and it takes time to become revalidated. In the end, your practice can lose money during the re-credentialing/revalidating process if done too late.

PrognoCIS Credentialing Services Can Help

Our credentialing team helps your practice complete all your required applications, manage your CAQH profiles and network contracts (including negotiations). We can also help you to expand your business by providing credentialing services at any new location you have.

PrognoCIS credentialing services include annual maintenance by tracking down expiration dates for documents such as medical licenses and DEA/CDS and can provide additional help with re-credentialing. We can also advise on updating your National Provider Identifier (NPI) as a group and as an individual.

Visit our credentialing page, or contact us to receive more information about PrognoCIS credentialing services or our EHR Software.


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