Form a Dedicated Credentialing Team

Written by on May 1, 2015 in Practice tips - No comments

Ensuring Smooth Cash Flow

Healthcare credentialing—the process by which providers are enrolled to participate with a particular insurer or healthcare organization—has always been a complicated one. This documentation-driven endeavor includes applications, screenings, primary source verification, and more. It’s something that must be done each time a new provider joins a practice or when providers change practices, merge their practices, join an Accountable Care Organization (ACO), or become acquired by a hospital system. It’s a tedious task that requires an impeccable attention to detail and deadlines.

HealthReflectionWEBOver time, the process of credentialing has become even more difficult to manage simply because of the oftentimes volatile nature of the healthcare marketplace. The Affordable Care Act and other quality-driven initiatives force providers to practice smart medicine and make business decisions with the best financial outcomes in mind. New providers enter the profession daily. Others switch practices frequently. Many physicians work with a nurse practitioner, physician assistant, or other non-physician practitioner, each of whom must be credentialed with various insurers.

What does all of this mean in terms of credentialing?

Credentialing is critical to overall financial viability because it ultimately enables reimbursement. If a provider is not credentialed correctly—or there has been a lapse in the credentialing process—he or she will not be paid. It’s important to think of credentialing as having no clear beginning and end—it is an ongoing task. As such, a dedicated credentialing team within the revenue cycle management department is required. Even after providers are approved, they must re-credential two years after the initial credentialing decision. The larger the organization, the more physicians and other providers there are to track, credential, and re-credential.

How a dedicated credentialing team can help

A dedicated credentialing team can address the following:

  • Adoption of credentialing standards to ensure compliance. This includes establishing policies and procedures that address standards for payers published by the National Committee for Quality Assurance as well as standards for providers published by the Joint Commission. The team can also monitor for any updates or revisions to these standards and update processes accordingly.
  • Credentialing management. This includes managing the entire credentialing process for credentials such as Controlled Dangerous Substance (CDS), Drug Enforcement Agency (DEA), Medical License, Council for Affordable Quality Healthcare (CAQH), Board Certification, Malpractice, and Hospital Privileges. In the event that a provider is not credentialed upon application, the team can appeal this decision, when appropriate.
  • Ongoing monitoring. This includes ensuring that all requirements are met, particularly as new providers join the practice or organization.
  • Re-credentialing. This includes developing processes to re-credential providers before their current credentialing expires.
  • Payer agreements. These agreements should outline responsibilities, develop metrics to assess performance, and identify ongoing oversight processes.

Most importantly, a dedicated credentialing team ensures communication among primary stakeholders, including providers, practice administrators, coders, billers, and others. This team can—and should—provide regular status updates regarding the credentialing that is in process vs. what has been completed and approved.

Why it’s important to act now

By constantly monitoring the credentialing process and identifying new opportunities for credentialing, a dedicated credentialing team reduces the overall risk for the practice and ensures that there are no payment gaps. As the credentialing process becomes more complex to manage, it’s important for practices to ensure that a team of individuals oversees relevant deadlines and requirements. The ongoing process of credentialing requires strict oversight to ensure success. Practices that dedicate resources to this effort will reap the financial rewards and prevent revenue loss.

By Vishal Gandhi, BSEE, MBA
CEO, ClinicSpectrum Inc.

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