Role Of Healthcare Credentialing In Standardizing Medical Care

For those who expect the best quality of medical care, nothing is enough to ensure the expertise, professionalism and competency of a healthcare provider. Healthcare credentialing is the ultimate means of offering that credibility to the medical practitioner.

Why is it necessary to have yourself credentialed?

The state and federal laws strictly require credentialing to make sure the care rendered meets a certain level of standard and quality.

From the part of a healthcare facility hiring you for the first time, it is the first step to prove your eligibility and skills in providing optimum care to their clients.

Credentialing is what it takes for the insurance companies to approve you and add you to their list of providers.

It gives immense relief and confidence to the patients to know that they are in the hands of an expert in the field.

Credentialing is mandatory not just for the doctors but chiropractors, physical therapists, nurses, counsellors, physician assistants and mental health therapists as well.

The process of healthcare credentialing happens this way:

Applying with the relevant information

All the basic information regarding education, training, graduation diplomas, special degree, licensure, former practice, background information etc are to be submitted.

Verification of the information

The board issuing practice license, med-school training, references from medical peers and previous malpractice claims if any are verified directly as well as using third party agencies. Both the healthcare facility and insurance companies run these background checks at the time of credentialing. Sometimes, the work history of the physician is looked into for deviation from the standards of care, medical negligence, death rates and patent readmissions.

Obtaining the credential

After the verification process is completed and no blemishes are found on the records of the practitioner, the credential is awarded to the provider. Until then, he/she cannot attend to patients or receive reimbursement from the insurance provider of the patient.

Credentialing with insurance companies

After setting up a practice, getting yourself enrolled in the insurance panel to receive payment for services to patients is the initial step. Here is what is required for provider credentialing:

1. Listing out all the insurance companies you want to make ties with from among the network.
2. Familiarizing with their credentialing policies and requirements.
3. Do frequent follow-ups with the ongoing process.
4. Choose the health plans and packages offered by the companies that are more cost-effective and money saving for the patient as well as clinician.
5. Get enrolled with maximum insurance payers to enable your patients to use whatever insurance card they have taken up.

Credentialing process can be done in two ways:

Manually

Where the clinical staff or the physician himself takes care of all the required paperwork, completes the forms, provides clarifications to the questions from the payers and follows up with the application. Sometimes, they use software for the purpose. Since the entire process is cumbersome, it is often recommended to seek help from professionals in the area.

With the help of professional credentialing services

They collect all the necessary data from the physician and store it in their cloud-based databases which can be accessed anytime for further clarification. Since they already keep a list of top payers in the network, contacts will be initiated for provider enrolment, sticking to the format mentioned in the payers’ contract. The status of the credentialing application and enrolment process is duly updated to the physician.

The entire process is much faster and avoids a backlog of paper works compared to doing it manually. Also, if properly credentialed, denials from the provider can be avoided to a great extent. Their service also includes keeping track of the expiration dates of licensing documents, certificates, attending continuing medical education programs etc and getting them renewed. Even automatic warnings on renewal requirements can be set up. Having an organized healthcare credentialing system helps you in maintaining compliance with the regulations and industry standards.

Benefits of having yourself credentialed

From the point of view of the healthcare facility, they can have the peace of mind of employing the best and competent set of providers. The added advantage will be the inflow of revenue to their institution. For the insurance provider, they can make sure they have teamed up with a compliant partner and for the patient, it will be a rewarding experience being cared for by the best and efficient.

Healthcare credentialing guarantees that a given provider perfectly fits in the medical fraternity. It not only improves your reputation but also reflects on the clinic’s revenue cycle. When all the medical staff in a healthcare facility are properly credentialed, the threat of possible lawsuits can also be alleviated to a good extent.

Hi, I am Manik Tyelor Content creator by profession... I write content for a variety of industries like Finance, Technology, HealthCare, Food, Revenue Cycle ManagementContent Marketing.