August 4, 2023

Medical Credentialing Services: How it Works and What it Costs

If you work in the healthcare industry, you probably know that medical credentialing services is a crucial process that you need to go through before you can offer your services to patients. 

But do you know what medical credentialing is, how it works, what it costs, and how it affects you and your patients? In this blog post, we will answer these questions and more. We will explain the basics of medical credentialing, the steps involved in the process, the advantages of obtaining medical credentials, the types of providers and facilities that require medical credentials, the role of regulatory and accrediting organizations in medical credentialing, and the tips to expedite and monitor the credentialing process.

What are Medical Credentialing Services?

Medical credentialing is the process of verifying and validating the qualifications, skills, and competencies of a healthcare provider or a facility. It involves checking the education, training, licensing, work experience, and other credentials of the provider or the facility against the standards and requirements of regulatory and accrediting organizations, such as The Joint Commission (TJC), The Centers for Medicare and Medicaid Services (CMS), and The National Committee for Quality Assurance (NCQA).

Privileging is the process of granting specific clinical privileges to a healthcare provider or a facility based on their credentials, scope of practice, and performance. Privileges define the types and levels of services that a provider or a facility can offer to their patients. For example, a physician may have privileges to perform surgery, prescribe medications, or admit patients to a hospital.

Why is Medical Credentialing Important?

Medical credentialing is important for several reasons:

• It ensures quality assurance in the medical industry by verifying that providers and facilities meet the standards of care and competence.
• It helps control costs for insurance companies by reducing fraud, waste, and abuse in billing and reimbursement.
• It expands patient access for healthcare providers by allowing them to participate in various insurance networks and contracts.
• It improves patient safety and care quality by preventing malpractice, negligence, and errors in diagnosis and treatment.

How Does Medical Credentialing Work?

The medical credentialing process varies depending on the type of provider or facility, the type of service or privilege requested, and the regulatory or accrediting organization involved. However, the general steps are as follows:

Application: 

The provider or facility submits an application to a credentialing verification organization (CVO) or a health plan that requests information about their credentials, such as education, training, licensing, work experience, malpractice history, references, etc. The application may also include a fee for processing.

Verification: 

The CVO or the health plan contacts the primary sources of the credentials to verify their accuracy and validity. Primary sources are the original issuers or holders of the credentials, such as universities, certification boards, licensing agencies, hospitals, employers, etc.

Review: 

The CVO or the health plan reviews the verified credentials and compares them with the criteria and standards of the regulatory or accrediting organization. The review may also involve checking other sources of information, such as peer reviews, quality measures, patient satisfaction surveys, etc.

Decision

The CVO or the health plan makes a decision to approve or deny the application based on the review results. The decision may also include granting or denying specific privileges to the provider or facility. The decision is communicated to the provider or facility and documented in their credentialing file.

Appeal: 

The provider or facility has the right to appeal the decision if they disagree with it or have additional information to support their application. The appeal process may involve submitting a written request for reconsideration, providing additional evidence or documentation, attending a hearing with a credentialing committee, etc.

The medical credentialing process can take anywhere from a few weeks to several months depending on the complexity and completeness of the application, the availability and responsiveness of the primary sources, and the workload and efficiency of the CVO or health plan.

What are the Advantages of Medical Credentialing?

Medical credentialing offers many advantages for both healthcare providers and facilities:

• Quality Assurance: Medical credentialing ensures that providers and facilities meet the highest standards of care and competence in their field. It also helps them maintain their credentials through periodic re-evaluation and updates. This enhances their reputation and credibility among patients, peers, regulators, insurers, and employers.
• Cost Control: Medical credentialing helps reduce costs for insurance companies by preventing fraud, waste, and abuse in billing and reimbursement. It also helps providers and facilities negotiate better rates and contracts with insurers based on their credentials and performance. This increases their revenue and profitability.
• Patient Access: Medical credentialing allows providers and facilities to participate in various insurance networks and contracts that cover millions of patients across different regions and markets. This expands their patient base and increases their market share.
• Patient Safety: Medical credentialing protects patients from malpractice, negligence, and errors in diagnosis and treatment by ensuring that providers and facilities have the necessary skills and qualifications to deliver safe and effective care. It also helps patients make informed choices about their healthcare providers and facilities based on their credentials and performance.

Which Healthcare Providers Require Medical Credentials?

Medical credentialing applies to all types of healthcare providers who offer direct patient care services. Some examples are:

• Physicians: Physicians are doctors who diagnose and treat diseases and injuries using various methods, such as medication, surgery, or therapy. Physicians require medical credentials to practice medicine in any state or jurisdiction. They also need to obtain board certification in their specialty or subspecialty to demonstrate their expertise and competence.
• Podiatrists: Podiatrists are doctors who specialize in treating disorders and conditions of the feet, ankles, and lower legs. Podiatrists require medical credentials to practice podiatry in any state or jurisdiction. They also need to obtain board certification in podiatry or podiatric surgery to demonstrate their expertise and competence.
• Ophthalmologists: Ophthalmologists are doctors who specialize in treating diseases and conditions of the eyes and vision. Ophthalmologists require medical credentials to practice ophthalmology in any state or jurisdiction. They also need to obtain board certification in ophthalmology or ophthalmic surgery to demonstrate their expertise and competence.
• Optometrists: Optometrists are doctors who specialize in examining, diagnosing, and treating vision problems and eye diseases. Optometrists require medical credentials to practice optometry in any state or jurisdiction. They also need to obtain board certification in optometry or optometric specialties to demonstrate their expertise and competence.

How Long Does the Credentialing Process Take?

The credentialing process can take anywhere from a few weeks to several months depending on the complexity and completeness of your application, the availability and responsiveness of the primary sources, and the workload and efficiency of the CVO or health plan. Some factors that can affect the duration of the credentialing process are:

• The type of provider or facility: Some types of providers or facilities may require more credentials or privileges than others, which can increase the time and effort needed to verify and review them.
• The type of service or privilege requested: Some types of services or privileges may require more criteria or standards than others, which can increase the difficulty and complexity of evaluating them.
• The completeness and accuracy of your application: If your application is incomplete, inaccurate, or inconsistent, it can cause delays and errors in the verification and review process. You need to make sure that you provide all the required information and documents in your application and that they are correct and up-to-date.
• The availability and responsiveness of the primary sources: If the primary sources of your credentials are not available or responsive, it can cause delays and difficulties in verifying them. You need to make sure that you provide accurate and current contact information for your primary sources and that you follow up with them if needed.
• The workload and efficiency of the CVO or health plan: If the CVO or health plan has a high volume of applications to process or a low level of resources or staff, it can cause delays and bottlenecks in the credentialing process. You need to check with the CVO or health plan about their expected timeframe for completing your credentialing process and monitor their progress.

How to Expedite the Credentialing Process?

If you want to expedite the credentialing process, you can follow these tips:

• Start early: You should start preparing your application as soon as possible, preferably before you apply for a job or contract with a health plan or a facility. This will give you enough time to gather all the necessary documents and evidence for your credentials and avoid any last-minute rush or hassle.
• Be organized: You should organize your application in a clear and logical manner, following the instructions and guidelines provided by the CVO or health plan. You should also label your documents and evidence properly and arrange them in a chronological order. This will make it easier for the CVO or health plan to review your application and find what they need.
• Be accurate: You should ensure that all the information and documents that you provide in your application are accurate and valid. You should also check for any errors, inconsistencies, or gaps in your credentials and address them promptly. This will prevent any confusion, misunderstanding, or suspicion from the CVO or health plan.
• Be responsive: You should respond to any requests or queries from the CVO or health plan as soon as possible. You should also follow up with your primary sources if they are not available or responsive. This will show your cooperation and professionalism to the CVO or health plan and speed up their verification process.
• Be proactive: You should monitor the status of your credentialing process regularly and communicate with the CVO or health plan if you have any questions or concerns. You should also update your credentials if there are any changes or renewals in them. This will show your interest and involvement in the credentialing process and avoid any delays or complications.

Conclusion:

Medical credentialing is a vital process that ensures the quality, safety, and efficiency of healthcare services. It involves verifying and validating the credentials of healthcare providers and facilities against the standards and requirements of regulatory and accrediting organizations. It also involves granting or denying specific privileges to providers and facilities based on their credentials, scope of practice, and performance. 

Medical credentialing can benefit both providers and facilities by enhancing their reputation, increasing their revenue, expanding their patient access, and improving their patient care. However, medical credentialing can also be a complex, time-consuming, and costly process that requires careful planning, preparation, and monitoring. That’s why you need a reliable partner like Atlantis RCM to help you with your medical credentialing needs. 

Atlantis RCM is a leading provider of medical billing and credentialing services that can help you streamline your credentialing process, reduce your costs, and increase your success rate. Contact us today to find out how we can help you with your medical credentialing.