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Understanding the process of credentialing is simple. It is a process that entails the procurement and verification of information that ascertains whether or not a physician is capable of fulfilling his or her medical obligations. The process is fundamental for everyone involved with the healthcare industry. This includes the practitioners, nurses, and of course, the patients. 

The credentialing process in itself, however, is burdensome, to say the least. A typical credentialing process can take 90 to 150 days to conclude. Hurdles like missing or incorrect information in the applications submitted can result in claim denials, which essentially means you’ll have to undergo the entire process all over again, costing you both valuable money and precious time. 

That being said, you can’t simply ignore the process either. Credentialing is important for a variety of reasons. 

• •     It can help build patient trust
• •     It lowers the risk of medical errors.
• •     It helps medical organizations from losing revenue
• •     It improves a practitioner’s reputation. 
• •     It can help you save costs
• •     It protects healthcare organizations from future lawsuits. 

Needless to say, the credentialing process is too valuable to pass. Yes, it can be uniquely frustrating to perform. However, we believe the following checklist can guide you competently for a smoother credentialing process. 

So without much further, allow us to acquaint you with the only Physician credentialing process checklist you’ll need for a seamless experience. 

  Physician Credentialing Process Checklist

The very first thing to do when starting the credentialing process is to make sure you are always one step ahead. The way to ensure that is by starting as early as possible. With that out of the way, you can begin the process. 

1. Submit the Pre-Application

It won’t take you time to notice or experience how tedious the credentialing process can be. To begin with, you will need to submit a pre-application based on the healthcare facility or insurance network you want to join. It is at this juncture in the process that insurance companies weed out applicants that are not eligible for credentialing. 

This step involves a background check. You will be checked for:

• •     Board Certifications
• •     Criminal Records
• •     Record of disciplinary action taken against you or your practice. 

If any issues arise here, you will be asked to submit further information. If there aren’t any issues, then you move on to the next step. 

2. Submitting the Applications

This step forms the actual meat of the process. You will be required to submit all information possible that vouch for your legitimacy as a healthcare provider. The most fundamental checklist will be as follows:

• •     Transcripts and educational history
• •     DEA registration
• •     Board certification
• •     Medical license
• •     Continual malpractice coverage
• •     Work history
• •     Professional and personal reference
• •     Explanation of gaps in work history
• •     Personal immunization record
• •     Personal health history
• •     CAQH Enrollment
• •     Hospital affiliation

All of the above information must be backed by solid documentation and relevant letters of recommendation. 

3. Receipt Verification

Once the application is submitted, you might feel inclined to take a sigh of relief. However, it will be too early to do so. In fact, we recommend constant follow-ups via call and emails to confirm that your application has been received and is under review. The credentialing board may reach out to you for further information. If that does happen, we recommend submitting the information as quickly as possible. Make sure you have copies of all the documents submitted ready at a moment’s notice. 

The above procedure entails the checklist for a traditional physician credentialing process. Medical practices may need to work with a new checklist to assist them in adding new providers. So if you are someone who runs a medical practice and wants to add a new provider to your staff, then the following checklist is for you.

  Checklist for adding a new provider

1. You will need to provide an updated CAQH profile with a new practice affiliation. Also, make sure the provider’s driving license and DEA are updated with the new state if the affiliation is different from their previous one.
2. The group that will be adding the new provider will be required to supplement a list of payers that they are currently affiliated with. This will include Medicaid HMOs, worker’s compensation, Tricare, Medicare advantage, etc.
3. Update your practice’s CAQH profile and supply tax companies with your Tax ID. 
4. You will be required to submit a new and updated malpractice policy and also update it in your CAQH profile. 
5. You will be required to provide the practice’s primary billing type. This information will be listed on your application with Tax ID. 
6. Mention Medicare’s PTAN that you plan to be included on. This information will be listed on the Medicare application of the new provider linked to your group. 
7. The following Documentation will be mandatory. 
   • •     Professional State License
   • •     Board Certification
   • •     CAQH Login and Password
   • •     PECOS Login and Password
   • •     PLI Certification
   • •     Professional School Diploma
   • •     State Medicaid Login and Password
   • •     Current CV with precise beginning and end date
   • •     Hospital Admitting Privilege
   • •     Certification of completing internships, fellowships, etc.

  The Bottom Line

Credentialing demands a plethora of information from practitioners. So much so that the whole process might feel a tad bit overwhelming. It also counts that all the information you do gather is complete and accurate. The consequences of failing to ensure that can be disastrous. 

So if you are still confused about the process and have no idea what information to carry, then we suggest you give our physician credentialing specialists at DENmaar a call. We are at your service whenever you need us. We’ll assist you with the entire process as well, making sure you make it on a payer’s network without a hassle. 

Contact us now to learn more. 

You would be wrong to assume that the credentialing process is over once a provider has been accepted into a payer’s network. In fact, providers are required to undergo routine screening and license verification to maintain compliance and provide quality care to their patients. This process that involves periodic screening and verification is what we call recredentialing. 

Recredentialing process is done to verify the training and qualifications of a provider and notify healthcare organizations if fraud or abuse is found. Now it is no secret that undertaking the credentialing process is no easy task. It can be time-consuming and burdensome. However, the cost of neglecting the procedure can be much direr. 

Hospitals and similar healthcare organizations are staring at revenue losses in the upwards of millions on litigation, delayed payments, and civil monetary penalties without recredentialing. 

Now that you know how important the process of recredentialing is, we will take a deep dive into the subject to make sure you learn everything there is to know about it. 

So without much further ado, let’s get started. 

Read More on Importance of Medical Credentialing

  How Many Time Does a Provider Need to Be Recredentialed?

The answer to this question will vary from state to state. In most American states, the provider must be credentialed immediately when hired. Later, they must undergo re-credentialing every two years. There are exceptions to this rule, however, as some states like Illinois require providers to be recredentialed every three years. 

To know exactly how often a provider needs to be recredentialed, it would be wise to check state laws and regulations that apply to your healthcare organization. 

  The Initial Requirements for Recredentialing

First and foremost, it is the responsibility of the healthcare organization to notify the doctors and nurses working under them at least 60 days before the recredentialing due date. Providers should be given access to all applications online. Remember, the recredentialing process varies from state to state and can take months to conclude. 

To expedite the process, we recommend keeping the necessary documentation on file. We also suggest preparing organization-specific requirements well ahead of time. If the process is too overwhelming to handle, we recommend you give us at DENmaar a call and our credentialing specialists will be happy to shoulder the recredentialing process on your behalf.

  Information Verified During Recredentialing

A traditional recredentialing process will entail the verification of the following documents:

• •     Drug Enforcement Administration or Controlled Dangerous Substances Certification
• •     State Licenses
• •     Board Certification
• •     Malpractice Claims History
• •     Work History
• •     Recent Malpractice Insurance Coverage
• •     Medicare and Medicaid Sanctions
• •     National Provider Identifier Number (NPI)
• •     State Sanctions and Restrictions on Licensure and Limitations on Scope of Practice. 

  What Happens When an Application is denied?

A provider is notified with a written notice that includes the reason for denial in case their application is rejected by the credentialing committee. Providers have the right to submit an appeal contesting the denial. The provider must request reconsideration in writing within 30 days of receiving a denial. 

The written request must be submitted along with the necessary documents. The reconsideration will be scheduled within 60 days. Remember, the provider has no further option if his or her claim is denied a second time. 

Learn More on How to Avoid Payer Rejection During Enrollment

  Getting Recredentialed Without a Hassle

Issues with recredentialing are more common than you would assume. That being said, there are ways by which you can make sure those issues never arise during your procedure. To begin with, healthcare organizations should maintain evidence of a provider’s application in a secure credentials file. They should also adopt a system that keeps all relevant information current. 

However, the only guaranteed way to make sure you don’t fail with recredentialing is to seek help from credentialing specialists in the industry like DENmaar. DENmaar has been helping healthcare organizations across the United States with credentialing provider enrollment for decades now. As such, we have the talent, resources, and insight needed to handle the complex process of credentialing at the behest of your healthcare organization. 

You can get in touch with us now to learn more about DENmaar’s recredentialing services. 

Getting enrolled into an insurance company’s network isn’t an easy task. Throughout the process, you’ll find that you have very little control over the outcome of the entire proceedings. You’ll find yourself at odds with the insurance companies whose network you so desperately want to join. Chances are that things might not pan out as you’d hoped. 

Payer rejection is a reality that most providers do not want to ever encounter. Sadly, hearing a straightforward ‘No’ from payers after a very lengthy application process is more common than you can imagine. Most of the times providers have no clue what led to the rejection. What exactly went wrong that warranted the denial of an application? You’ll probably never know. 

You can take solace in the fact that you are not the only healthcare provider in America that had to go through this ordeal. Getting paneled is not easy. It isn’t impossible either or as complicated as most people spell it out to be. There are a few steps or measures a provider can take to overcome a denial during enrollment. 

This article will give you a peek at those tips, but first… let’s understand why application denials even happen in the first place. 

  Reasons for Insurance Panel Denials

You have to understand that insurance companies have the ultimate power to set and adjust the number of providers they accommodate into their network. Payers want to save costs for themselves while at the same time trying to fulfill the promise of better healthcare that they’ve made to their enrollees. As such, payers have a plethora of reasons to deny applications. 

They can reject an application because of an error in the application, wrong or missing information, or if the provider doesn’t meet the dictated qualification criteria. Payers may also reject an application if they are currently not accepting providers belonging to a specific demographic.

Read More: Importance of Medical Credentialing

Other typical reasons for payer rejection maybe because of the following:

• •     Failure to meet provider standards as dictated by the payer. 
• •     Over-saturation of a provider type pertaining to a service area or community.
• •     The provider failed to comply with the payer’s conditions of participation.
• •     The provider failed to meet requirements pertaining to out-of-state enrollments. 

  Persistence is Key to Overcoming Payer Rejection

Normally it’s typical of providers to simply give up once their application has been rejected. However, what they aren’t aware of is that they still have time to turn the tides in their favor. There are, in fact, a ton of things you can resort to in a bid to overturn your rejection. We know this can be daunting. As such, we highly recommend hiring a credentialing specialist to advocate at the behest of your case in front of the payers. 

To begin with, try to request a face-to-face meeting or a conference call with the decision-makers to clearly convey your case. Remember, persistence is the key. Do not take ‘no’ for an answer. Reach out to the authorized personnel in the payer’s office to understand why your application was rejected and what you can do to fix the situation. 

You can use LinkedIn to find the right people to talk to. For instance, go to LinkedIn and search employee titles under the payer’s company name. Try to connect with provider management representatives and initiate a conversation with them. 

Most of the time, the reason behind denials has to do with the provider type. In such a scenario, providing more information even though the payers haven’t asked for it can make a lot of difference. Convey the demographic and the patient population you serve as a healthcare provider. This is more important if the demographic is related to any of the following:

• •     Non-English-speaking communities.
• •     Rural
• •     Disabled
• •     Geriatric
• •     Pediatric
• •     Chronic Condition

  Steps to Take for Simple Provider Enrollment

You can try several things to get yourself enrolled successfully on the insurance company’s panel. A few of the things you can try are as follows:

• •     Get letters that convey support from the community you serve. 
• •     Seek a second-level appeal from a decision-maker or manager of the insurance company. 
• •     Suggest a trial period where you will only serve a select number of patients, offering free comparison analysis when that period has concluded.
• •     Make use of a phone instead of email or letters to clearly convey your message. 
• •     Request a face-to-face meeting and set up a conference call. 
• •     Compose a letter that shines a positive spotlight on the services of your practice or clinic. 
• •     Host an in-service visit to help payers better understand your services. 

Learn more on Medical Credentialing Process

Getting paneled with an insurance company is no child’s play. It is an excruciatingly long process with multiple moving parts. One wrong move and you must undertake the entire enrollment process all over again, which can be both time-consuming and costly. As such, it is in your best interest to seek the help of credentialing specialists to guide you throughout the process. 

This is where DENmaar’s provider credentialing services come into play. DENmaar is home to highly qualified credentialing experts that shoulder the responsibility of provider enrollment on your behalf. We do not rest until your place on the payer’s panel is secure. 

To learn more about our credentialing and provider enrollment services, we recommend you contact us today.