Provider Re-credentialing – Explained

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.