The Do’s & Don’ts of Medical Credentialing

March 14th, 2022 /
Shani Yellin
/ 6 Min Read

Overview

Through medical credentialing, it’s possible to better serve all your patients and boost your revenue cycle performance. You must take the right approach from the very start, and then properly maintain your status as an in-network provider. Otherwise, you’re likely to land right back at square one, resulting in wasted time, money, and effort.  

Don't and don'ts of credentialing

Fortunately, we are here to help with this informative guide on the dos and don’ts of medical credentialing. So, if you’re ready to take your practice to the next level, take a peek at the following to learn all you need to know about this process.  

What is Medical Credentialing? 

Medical credentialing is the process of becoming an in-network provider for an insurance carrier. Also known as payer enrollment, this process involves the verification of your medical license, malpractice insurance, and DEA (Drug Enforcement Administration). Plus, they’ll look at your education and background check information. After the credentialing process is complete, most payers will need to sign a contract to finalize their enrollment.  

The credentialing process varies by state as well as individually for each insurance company. You must select the insurance companies you want to credential with, and then complete the process for each one.  

To figure out which networks to join, look at which companies your main competitors and local hospitals use. Then, reflect on which providers you get referrals from on a regular basis. Plus, explore major employers in your area to see which insurance networks come up most often.  

Types of Medical Credentialing  

There are two main types of credentialing: 

  1. Delegated: Completed in-house by a large hospital or practice  
  2. Direct: Performed by the insurance company itself  

Delegated and direct medical credentialing are not always interchangeable. If moving from a delegated to direct process, you may need to start anew, depending on state guidelines and the insurance company’s policies.  

Most Common Medical Credentialing Mistakes  

Even when completed perfectly, medical credentialing is not a quick process. Mistakes can extend the timeline even more, so they’re well worth taking the time to avoid.  

The most common medical credentialing mistakes include: 

  • Leaving any sections blank while filling out forms  
  • Failing to update your information on a regular basis 
  • Delegating credentialing to an inexperienced staff member  

Failing to follow up with the insurance companies can extend the timeline considerably as well.  

Without any mistakes, expect the credentialing process to take about three to six months on average. If you are fresh out of school or switching states, it’ll take even longer.

Do’s and Don’ts in the Credentialing World  

With an understanding of the key dos and don’ts, you can help avoid common pitfalls and delays in the credentialing process. Also, practicing your due diligence will help you stay in good standing through the years. Here are a few things to keep in mind as you move through each process.  

Do’s  

1. Start Early  

An early start is key in getting your credentialing squared away in the average three-to-six-month timeline. Delays often happen at the beginning of the year and again in August. Since processes differ at the company level, it’s common for certain insurance companies to take longer than the norm. Furthermore, state-level differences can extend things out longer than you might like. 

2. Maintain All Documents 

Maintaining all your documents is necessary through the initial credentialing phase and beyond. To start, you need to create a profile in the Council for Affordable Quality Healthcare, or CAQH, system. Then, you must update it on a 90- to 120-day schedule to keep the database up to date always. Beyond that, you must complete your DEA, license, and malpractice insurance renewals on time. Plus, update your CV with your new practice info.  

3. Know the Regulations  

Every insurance carrier and the state has its own regulations. So, be sure to pay close attention to all their rules or risk getting penalized. Your claims could get denied or delayed if you don’t. Or you might even end up losing your status as an in-network provider.  

4. Expect Extra Fees 

The credentialing process often comes with extra fees, especially when it comes to Medicare and Medicaid. The fees can range from $100 to over $600, depending on the carrier. So, just be ready to pay the additional amount when you file your application.  

Don’ts  

1. Do Not Assume All is Well  

Timely follow-ups are a must while completing payer credentialing. Check-in with the insurance company after submitting documents to ensure it was received. Then, check back every one to two weeks to confirm processing. You may need to provide additional information after submitting the application. Check for mistakes along the way to make sure all is well.  

2. Avoid Waiting Until the Last Minute  

Every step in the credentialing process takes time, so don’t wait until the last minute to complete key steps. Update your CAQH data regularly and don’t miss an attestation deadline. Start license renewals well ahead of time. And just generally allow for long turnaround times every step of the way.  

3. Don’t Assume You’re in Network Across the Board 

Upon completing credentialing with an insurance carrier, do not just assume you are in-network for all their products. Get a list of all the plans under the contract. Then, check to see if you need to apply separately for any of their other products.  

4. Never Forget to Revalidate  

Forgetting to revalidate your credentialing can instantly halt payments coming your way. And it’s not quick and easy to get started back up again. If you miss a re-credentialing deadline, you may have to restart the entire process, which could result in a three- to six-month delay. Start the revalidation process about 90 days (about 3 months) ahead of time to avoid all that.  

Top Benefits of Using a Credentialing Service 

Although payer credentialing might seem like a huge ordeal, joining insurance networks can make all the difference to your patients. Beyond that, it is a great way to boost your revenues and take your practice to the next level. If it all seems like too much to take on, then you need a credentialing service on your side. 

Bizmatics credentialing service can assist with completing the applications for each insurance carrier. Plus, the team will manage your CAQH profile, help with network contracts, and assist in expanding your business.  

Sign up for the yearly maintenance package and the support continues all year. You will not have to lift a finger to stay on top of your CAQH profile info, expiration dates, and more. You will even get access to all the advice you need regarding which networks to join and when.  

Key Takeaways  

  • Medical credentialing can improve the patient experience and increase your practice revenue.  
  • The payer credentialing process allows you to become an in-network provider for insurance companies.  
  • Credentialing usually takes three to six months if you do not make any mistakes along the way. 
  • You must approach credentialing as an ongoing process to stay in-network with the insurance companies.  
  • Getting help from a credentialing service can help streamline the process and ensure you stay in compliance.  

 Here are some helpful resources to look into:

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