Medical credentialing is very important. It ensures that patients get treated by practitioners with the right qualifications to provide the best care possible. Because of this, payers are very careful about ensuring that care providers are correctly qualified. They do this by using a strict system of checks when a medical claim is made to ensure the credentials are correct.

However, maintaining the proper provider credentials can be challenging to avoid payment denials and delays. This is especially a problem for larger healthcare organizations that are always bringing in new care providers. Here are some tips for best practices in medical credentialing that can help.

More Denials Due to Credentialing Issues

Medical credentialing is important to protect patients, payers, and providers. However, denials caused by credentialing are becoming more common in healthcare. According to a survey conducted in 2021 by the Medical Group Management Association (MGMA), 54 percent of practitioners experienced more denials from payers due to credentialing problems.

The problem is that credentialing processes and requirements have changed in recent years. Many groups have established rules and standards for how credentialing should be done. This makes it a difficult and time-consuming task to keep both current and new providers properly credentialed. Healthcare organizations spend $39 billion annually on administrative tasks for regulatory compliance. With so much to handle, credentialing tasks can easily be neglected. 

Here are 12 tips to help you with medical credentialing:

Begin the licensing process early

 It's essential for new practitioners to start the licensing process as soon as they can. This ensures a smooth transition from educational programs to practice. Different providers have different licensing processes, and each process takes a different amount of time to complete. For example, Physician's Assistants (PAs) need certification from the National Commission on Certificate of Physician's Assistants. This certification involves multiple steps, such as verifying education and citizenship, and might require peer references. 

Make sure to update the contact information of all doctors regularly.

Even a small mistake, like having the wrong address for a doctor or someone who can vouch for them, can cause issues with medical credentialing. So, make sure you keep the contact information for doctors and other providers up to date. If you can't easily communicate with a particular provider, it can slow down the process when a payer questions their credentials.

Outsource Medical Credentialing

Medical credentialing takes a lot of time. It's easy to make mistakes, which can cause problems later. It's a good idea to hire a medical billing services provider to handle your credentialing process. They have experts who will check and record all the necessary information for the providers in your organization.

Understand the rules in your state

 Each state has its regulations for medical professionals. It's crucial to know them, especially if your organization has providers who move between states to work. Not updating their credentials for each state can cause issues when filing claims.

Track Credentialing Applications

 After you submit your credentialing applications to an insurance company or organization, make sure to keep track of their progress. Don't hesitate to contact the insurance company and ask about the status of your application. Sometimes, insurance companies put aside applications that are incomplete and fail to inform providers promptly.

Get a Special DEA Number

To prescribe medication, providers must have a DEA number. Providers usually need a number for each state they work in, but the rules can differ. After applying through the DEA website, the applications may take a few weeks to be processed.

Obtain an NPI number

 Healthcare providers are assigned National Provider Identifiers (NPIs). It is important for providers to keep their NPI information up to date. If a provider does not have an NPI or their information is inaccurate, it can lead to claim denials by payers. To prevent this, practitioners must promptly update their information through the National Plan and Provider Enumeration System (NPPES) website whenever their status changes. Providers can avoid complications with claim processing by ensuring accurate and current NPI information.

Get Records of Procedures Patient History

Healthcare jobs often require evidence of previous work experience. To prove your experience, ask for records of procedures or activities and keep them for reference. 

Review Malpractice Lawsuits

Keep a detailed record of past malpractice lawsuits, including information about the insurance companies involved and policy numbers for malpractice insurance. Make sure to have a copy of the provider's insurance certificate for your records.

Conclusion

A provider's credential file contains licenses, numbers, and identification forms that have expiration dates. If these documents expire without notice, it can cause issues with credentialing. Make sure to keep track of the expiration dates for each provider's credentials in the organization.

FAQs

What is medical billing and credentialing?

Medical billing and credentialing involve healthcare providers getting approved by insurance companies. Trustworthy insurance companies only include providers who have been checked and verified.

What are the elements of credentialing?

Credentialing includes various factors like education, training, licenses, work history, malpractice claims, criminal background, and judgments. Education is particularly important for providers seeking credentialing with a payer.