In healthcare, provider credentialing can feel like a maze. You go in with a clear goal and a lot of hope. Then, you get lost in the paperwork, the confusion, and the unexpected delays. Getting a qualified provider in-network can take time—especially if the organization lacks an efficient system for credentialing providers. 

The longer it takes to get a new or out-of-network provider on board, the more it costs your organization and patient care. This article offers insights to help healthcare organizations like yours avoid the pitfalls of healthcare credentialing. Innovative data management can empower your team to move faster, streamline operations, and improve patient care.

Azulity’s provider credentialing services can help you achieve these goals. Our solution can simplify and accelerate provider credentialing so your team can enhance operational efficiency, reduce costs, and boost patient care.

What is Provider Credentialing In Healthcare?

Credentialing in healthcare refers explicitly to verifying and evaluating the qualifications, credentials, and background of healthcare providers, such as physicians, nurses, and other allied healthcare professionals, before allowing them to provide patient care. 

This process typically involves thoroughly reviewing the provider’s education, training, licensure, certification, work history, and other relevant information to ensure they meet the standards and requirements set forth by regulatory bodies, healthcare organizations, and insurance companies. Provider credentialing ensures patients receive safe, high-quality care from qualified and competent healthcare providers.

What are the Benefits of Provider Credentialing? 

There are several benefits of provider credentialing for healthcare providers. Following are some of the most important ones: 

Ensures compliance

Provider credentialing ensures that healthcare providers comply with state and federal regulations and industry standards by verifying their qualifications and credentials. 

Enhances patient safety

Credentialing verifies that a healthcare provider is qualified and competent to provide the care and services they offer, which helps ensure patient safety and quality of care. 

Builds trust

Patients are more likely to trust healthcare providers who have been adequately credentialed and have undergone thorough background checks. This trust can lead to increased patient satisfaction and retention. 

Facilitates contracting

Credentialing is often a requirement for healthcare providers to participate in insurance networks and other reimbursement programs. By meeting these requirements, providers can expand their patient base and increase revenue. 

Reduces liability

By verifying a healthcare provider’s credentials, healthcare organizations can reduce their liability in the event of malpractice or other issues and help protect their reputation. 

Improves efficiency

Credentialing can help healthcare organizations streamline operations by ensuring that all providers meet the same standards and requirements. This can lead to more efficient workflows and better patient outcomes. Provider credentialing is essential for providing quality patient care, protecting healthcare providers and organizations, and building patient trust.

7 Key Steps for Seamless Provider Credentialing

1. The Provider Submits an Application to the Insurance Company 

The provider starts the credentialing process by applying to the insurance company. This application requests that the insurance company credential the provider to join their network. The application usually includes personal and professional information such as education, licensure, and board certification. 

2. The Insurance Company Verifies the Provider’s Credentials

Next, the insurance company verifies the provider’s credentials. This includes checking education and training, licensure status, and board certification. 

3. The Insurance Company Performs a Background Check

The insurance company performs a background check on the provider to ensure they do not have any criminal history or disciplinary actions taken against them by any regulatory bodies. 

4. The Insurance Company Verifies the Provider’s Insurance

The insurance company verifies that the provider has adequate malpractice insurance coverage. 

5. The Credentialing Committee Reviews the Application

The insurance company’s credentialing committee reviews the application and supporting documentation to determine whether the provider meets the insurance company’s credentialing requirements.

6. The Credentialing Committee Makes a Decision

The credentialing committee decides to approve or deny the provider’s application. 

7. The Provider is Notified of the Decision

Finally, the provider is notified of the decision and, if approved, is added to the insurance company’s network of providers. 

Azulity specializes in healthcare master data management and provider credentialing services, bringing proven expertise in implementing healthcare data solutions and credentialing across the US. Our comprehensive platform ensures consistent patient, provider, location, and claims data synchronization across all systems and departments. 

Key features include healthcare MDM, provider MDM, reference data management, credentialing, and provider enrollment. We serve healthcare technology leaders – from CIOs and CDOs to VPs of data platforms and credentialing – helping them eliminate the costly problems of fragmented data systems. Book a call to learn more about our healthcare master data management services today!

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7 Tips for Efficient Provider Credentialing in Healthcare

1. Utilize the Power of Azulity for Efficient Provider Credentialing  

Azulity can transform your provider credentialing process. They specialize in healthcare master data management and provider credentialing services, bringing proven expertise in implementing healthcare data solutions and credentialing across the US. Their comprehensive platform ensures consistent patient, provider, location, and claims data synchronization across all systems and departments. 

Key features include healthcare MDM, provider MDM, reference data management, credentialing, and provider enrollment. They serve healthcare technology leaders from CIOs and CDOs to VPs of data platforms and credentialing, helping them eliminate the costly problems of fragmented data systems. Book a call to learn more about their healthcare master data management services today!

2. Know Which Documents You Need  

Each insurance company has its own set of guidelines for credentialing. A single document can ensure your application is completed on time. Start by identifying all the insurance providers you want to work with. Then, collect the required documents for each one. These often include: 

• Social Security Number
• Name
• Demographic information (origin, gender, ethnicity, and spoken languages)
• Qualifications and residency details
• Proof of licensure
• Professional experience
• Specialties and patient care
• Claims record
• Proof of insurance 

This information will be included in your provider’s applications and CV. However, you must verify its authenticity. 

3. Prioritize Insurance Providers  

Since you may need to submit applications to multiple insurers, prioritizing the order in which you file them pays. If a large percentage of your billing goes to a particular insurance provider, complete their healthcare credentialing form first. Stay up to date on individual health insurance rules. Some insurers allow providers previously credentialed in another state to undergo a simplified process. This could result in faster approvals. Additionally, many insurance providers have shortened the application process to providers already credentialed elsewhere. 

4. Ensure All Information is Accurate  

Accuracy is critical when compiling the necessary documents and completing individual applications. Before filing any applications, follow these procedures: 

• Run a full background check on the provider
• Verify educational background, licenses, certifications, and reputation with the AMA, ECFMG, and ABMS healthcare groups.
• Examine the provider’s claims history, credentials, and any advantages. 

Once you’ve gathered and reviewed these documents, you can present them to facility administration, who will determine which specific privileges to award the provider. This information is crucial for the credentialing process. 

Other options include

• Credentialing software: The ideal credentialing software saves data and can include features that make the credentialing process simpler and more efficient. 
• Outsourcing: Is your human resources department overburdened with medical credentialing services? Using a medical credentialing service or outsourcing the work will likely reduce time and costs. 

5. Complete the CAQH Process  

Several large medical insurers mandate partner clinics to register for CAQH accreditation (Simultaneously, they must register their applications). Once your clinic has submitted a form to a specific insurer, they will give you a Council for Affordable Quality Healthcare (CAQH) ID number and an invitation to register. 

All information must be correct to ensure CAQH clearance. Be ready to re-attest after submitting your initial application. What is re-attestation? – To maintain ongoing insurance eligibility, one must verify whether a provider’s data is accurate four times yearly. 

6. Wait for Verification  

After you’ve compiled and filed the application with insurance providers, it’s time to wait patiently for their official approval. This could be a lengthy process. Although many medical credentialing applications can be completed in 90 days or less, experts recommend allowing 150 days. Healthcare credentialing can take much longer if significant issues arise. 

7. Keep Track of the Process  

Don’t wait five or six months for an insurance provider to contact you. Credentialing medical specialists reveals the importance of continuous follow-ups for quick approval. Develop connections with key insurance personnel. Building a good working relationship with management, executive associates, and other staff members could help ensure your application is processed quickly. Instead of following up through email to boost response rates, use the phone. If you notice that more information is needed, compile and check all documentation as quickly as possible.

Related Reading

• Credentialing and Privileging
• How Much Does Credentialing Cost
• Types of Credentialing in Healthcare
• Hospital Credentialing Requirements
• Provider Enrollment and Credentialing
• Primary Source Verification Credentialing

What Problems Does Provider Credentialing Solve In Healthcare?

Ensuring Patient Safety and Quality Care

Credentialing verifies that healthcare providers have the qualifications, training, and licensure to practice. This reduces the risk of unqualified or underqualified professionals delivering care. 

Problem Solved

It prevents medical errors and ensures patients receive care from competent professionals. 

Example

Verifying a surgeon’s board certification ensures they meet the standards for performing specialized procedures. 

Regulatory Compliance 

Healthcare facilities must adhere to strict legal and accreditation standards. Credentialing ensures compliance with requirements set by regulatory bodies like The Joint Commission (TJC), CMS, and state medical boards. 

Problem Solved

Avoids legal issues, fines, or loss of accreditation for non-compliance. 

Example

A hospital that maintains up-to-date credentialing records avoids penalties during audits. 

Reducing Liability and Risk 

Credentialing helps healthcare organizations identify and mitigate malpractice, fraud, or unethical behavior risks by thoroughly reviewing provider backgrounds. 

Problem Solved

It lowers the risk of malpractice claims and protects the institution’s reputation. 

Example

Checking a physician’s malpractice claims history reveals patterns of concern that can influence hiring decisions. 

Facilitating Insurance Reimbursement 

Most insurance companies require credentialed providers before reimbursing claims. Credentialing ensures that providers are in-network and eligible for payment. 

Problem Solved

Prevents claim denials and revenue loss for healthcare organizations. 

Example

A clinic that ensures its new physician is credentialed with major insurers experiences uninterrupted reimbursements for patient visits. 

Enhancing Patient Trust 

Credentialing reassures patients that their healthcare providers meet industry standards for knowledge, skills, and professionalism. 

Problem Solved

It builds confidence in the healthcare system and fosters patient loyalty. 

Example

Displaying credentials and certifications in patient-facing areas helps build trust. 

Streamlining Operational Efficiency 

Credentialing systems and processes provide a standardized approach to onboarding providers, ensuring readiness to practice quickly. 

Problem Solved

Reduces administrative delays in integrating new providers into the healthcare team. 

Example

A hospital using automated credentialing software speeds up the approval process for new hires. 

Supporting Credential Reciprocity 

Credentialing supports simplified verification processes for providers moving between states or facilities, enabling continuity of care. 

Problem Solved

It minimizes delays in provider relocations or multi-state practices. For example, a telehealth provider credentialed in one state can more easily get approval to practice in another through credential reciprocity programs. 

Meeting Payer Requirements 

Many insurance payers mandate credentialing to establish network contracts with providers, ensuring both parties align on professional and legal standards. 

Problem Solved

Ensures compliance with payer-specific rules, reducing contractual disputes. 

Example

A cardiology practice avoids losing its contract with a major insurer by maintaining accurate and current provider credentials. 

Book a Call to Learn More About Our Provider Credentialing Services

Provider credentialing is a complex, multifaceted process that aims to ensure that healthcare professionals are qualified to provide the contracted services and to verify their competence through a thorough review of their training, experience, and any history of adverse incidents. 

Credentialing verifies the qualifications of practitioners within a certain period, while privileging assesses explicitly their ability to perform certain services or procedures at a particular organization. Provider credentialing takes time and is expensive, and studies show that nearly 40% of all healthcare revenue is tied to provider data. The more accurate and complete this data is, the more likely the organization will be able to avoid costly claim delays and denials. 

What’s the Difference Between Credentialing and Enrollment?

Credentialing and enrollment are often confused, but they’re distinct processes. Credentialing verifies that a provider is qualified to deliver the contracted services. At the same time, enrollment is setting up a provider with a payer. This includes collecting and verifying the same data types as credentialing but also involves creating a profile for the practitioner within the payer’s system so that claims can be paid when services are rendered. 

This process can take weeks to months, and delays can significantly impact revenue cycle operations. Some studies suggest that up to 90% of initial claims submissions for new providers are denied, often due to enrollment-related issues.  

Who Needs to Be Credentialed?

Though most healthcare organizations only have credentialed physicians, the process should include allied health professionals, such as nurse practitioners and physician assistants. Additionally, as healthcare increasingly relies on teams to deliver patient care, organizations should also credential the members of these teams, regardless of their specialty or discipline. 

This will help ensure all team members are qualified to deliver safe and effective patient care. Finally, organizations should also consider credentialing telehealth providers and locum tenens practitioners to help mitigate risk and ensure quality care. 

Why Is Provider Credentialing So Important?

Credentialing directly impacts patient safety and quality of care. The process helps to ensure that providers are qualified to deliver the services they are contracted to provide. The more robust an organization’s credentialing process is, the more likely it will be able to identify red flags that could pose a risk to patients. This is particularly important in today’s healthcare environment, where teams increasingly deliver care to individuals from various disciplines and specialties. 

Utilize the Power of Azulity for Efficient Provider Credentialing  

Azulity can transform your provider credentialing process. They specialize in healthcare master data management and provider credentialing services, bringing proven expertise in implementing healthcare data solutions and credentialing across the US. Their comprehensive platform ensures consistent patient, provider, location, and claims data synchronization across all systems and departments. 

Key features include healthcare MDM, provider MDM, reference data management, credentialing, and provider enrollment. They serve healthcare technology leaders from CIOs and CDOs to VPs of data platforms and credentialing, helping them eliminate the costly problems of fragmented data systems. Book a call to learn more about their healthcare master data management services today!

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