A new doctor is excited to start her new job at a bustling hospital. After an extensive interview, she is eager to meet her colleagues and treat patients. But first, she must complete the credentialing process—which could take a few weeks to a few months to finish. This investigation can feel like a background check for doctors. Like background checks, it can cause delays that frustrate the provider and the healthcare organization.
Credentialing verifies that healthcare providers have the proper training and licenses to deliver safe, effective care. This process can be incredibly tedious for facilities that need an organized system to manage the volumes of data involved. This guide explores the types of credentialing in healthcare and how they can impact provider credentialing. Understanding these different types of credentialing can help healthcare organizations improve their processes for faster, more efficient provider enrollment.
As healthcare organizations strive to meet the ever-increasing demands for quality care, Azulity’s provider credentialing services offer a practical solution. Our innovative approach helps allow healthcare organizations with data management tools designed to streamline the credentialing process for faster results.
Types of Credentialing in Healthcare
1. Physician Credentialing: Ensuring Qualified Healthcare Providers
Physician credentialing confirms the qualifications and background of a healthcare provider applying for a new job or a contract. This process examines a physician’s training, education, and professional history before they can practice at a new facility. Physicians who are joining a new hospital or clinic typically undergo this process. Physician credentialing can be conducted by the facility’s recruitment or administration teams. A professional credentialing organization can also complete this process.
2. Insurance Credentialing: What to Know about Insurance Networks
Insurance credentialing is when a health insurance company confirms a physician’s credentials. In this process, insurers check a provider’s credentials before determining them as an “in-network” provider. This helps confirm that the provider is a good option for those in their insurance plan.
3. Medical Sales Representative Credentialing: Why It Matters
Credentialing for medical sales representatives is a check conducted on those who sell medicine, healthcare, or other related services. This type of credentialing confirms and monitors the background and training completed by those selling healthcare services. The intention is to remove bad actors and keep patients safe.
4. Professional Credentialing: Verifying Healthcare Qualifications
Professional credentialing focuses on assessing individual healthcare providers’ qualifications and professional backgrounds. This credentialing typically involves verifying educational degrees, licenses, certifications, and training programs completed by the provider. It also includes evaluating work experience, references, and any professional affiliations. Professional credentialing ensures that healthcare professionals have met the necessary educational and training requirements to practice in their respective fields.
5. Facility Credentialing: Evaluating Healthcare Organizations
Facility credentialing focuses on evaluating healthcare facilities, such as hospitals, clinics, and ambulatory surgical centers. This type of credentialing assesses the facility’s compliance with regulatory and accreditation standards, including proper licensing, facility policies and procedures, quality assurance programs, and patient safety measures. Facility credentialing is essential for healthcare organizations to participate in insurance networks and provide patient services.
6. Payer Enrollment Credentialing: Understanding the Basics
Payer enrollment credentialing focuses on enrolling healthcare providers and facilities in insurance networks. It involves submitting the necessary applications, forms, and documentation to insurance companies and payers for participation in their networks. Payer enrollment credentialing ensures that providers can bill and receive payment for their services to patients covered by specific insurance plans.
Importance of Different Types of Credentialing in Healthcare
1. Physician Credentialing: The Gatekeeper to Qualified Medical Care
Credentialing physicians ensures that only qualified and experienced doctors practice in healthcare settings. This process safeguards patients by establishing their safety and institutional credibility. In 2021, Mayo Clinic’s stringent physician credentialing process helped the facility maintain compliance with The Joint Commission’s standards. As a result, the hospital preserved its reputation as a top-tier healthcare provider.
2. Insurance Credentialing: The Key to Affordable Care
Insurance credentialing is critical for enabling providers to offer affordable services to patients through insurance networks and maintaining trust between providers, insurers, and patients. For instance, when Blue Cross Blue Shield (BCBS) credentialed a new group of physicians for Cleveland Clinic, they verified medical licenses, certifications, and malpractice history to ensure these providers met BCBS standards. With this vetting, patients could avoid higher costs or receive care from unverified providers.
3. Medical Sales Representative Credentialing: Ensuring Ethical Practices
This type of credentialing ensures that medical sales representatives selling products to hospitals or physicians are qualified, ethical, and well-trained to avoid harm caused by misinformation or unethical practices. In 2022, credentialing ensured that Pfizer’s reps who promoted the company’s COVID-19 vaccine to hospitals met regulatory and compliance standards. This prevented unauthorized access and maintained Pfizer’s integrity in the healthcare community.
4. Professional Credentialing: Validating Qualifications
Professional credentialing validates the qualifications of individual healthcare providers, ensuring they have met the necessary standards to practice safely and effectively. The American Nurses Credentialing Center (ANCC) oversees professional credentialing for nurses. For example, Johns Hopkins Hospital requires ANCC-certified nurses to verify their education, licensure, and clinical experience before hiring. This rigorous process supports the hospital’s Magnet designation for nursing excellence.
5. Facility Credentialing: Ensuring Quality Care
Facility credentialing assesses healthcare organizations’ compliance with regulatory and accreditation standards to ensure they provide safe and effective care. In 2023, Cleveland Clinic underwent credentialing by The Joint Commission, a significant accrediting body, to renew its accreditation. The process involved evaluating facility safety, patient care protocols, and staff training programs. The renewal allowed Cleveland Clinic to maintain its Medicare funding and uphold its reputation as a leading healthcare facility.
6. Payer Enrollment Credentialing: Enabling Smooth Transactions
Payer enrollment credentialing ensures providers and facilities can bill insurance companies for their services, allowing smooth patient care and financial transactions. For instance, UnitedHealthcare performed payer enrollment credentialing for Kaiser Permanente facilities in California. This credentialing involved verifying Kaiser Permanente’s providers and facilities, ensuring they adhered to UnitedHealthcare’s standards, and allowing their inclusion in insurance networks. This streamlined patient billing and reimbursement processes.
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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9 Tips for Efficient Credentialing In Healthcare
1. Embrace Azulity for Efficient Credentialing
Azulity specializes in healthcare master data management and provider credentialing services, with proven expertise in implementing healthcare data solutions and credentialing across the United States. Their comprehensive platform helps ensure consistent patient, provider, location, and claims data synchronization across all systems and departments.
This helps healthcare organizations eliminate the costly issues of fragmented data systems. Azulity serves healthcare technology leaders, from CIOs and CDOs to VPs of data platforms and credentialing. Book a call to learn more about Azulity’s healthcare master data management services today!
2. Get Ready for Credentialing
The credentialing process can overwhelm healthcare providers due to the many documents involved. The process has two steps:
Credentialing
The credentialing phase is when the insurance company checks all your credentials and verifies whether you meet their requirements for participating in their network.
Contracting
In the contracting phase, the company issues you a participating provider agreement that defines the terms of participation for receiving in-network reimbursement for your claims.
3. Attend to Insurance Companies First
You could be required to submit many applications to get credentialed. Therefore, it could be beneficial to prioritize the dossiers you file. For example, if you send many of your billing to a single insurance provider, finish out their healthcare credentialing form first. Stay up to date about individual health insurance rules. Some health insurers allow providers already insured in that other state to go through a simplified process that could result in faster approvals. Many insurance providers shortened the application process to providers who have already been credentialed throughout.
4. Verify Correct Info
Now, the accuracy and standard of data are crucial when you start compiling the necessary papers and filling out individual applications. Follow these procedures before filing any applications: Run a full background check. Check educational background, license, professional certification, and reputation with healthcare groups like AMA, ECFMG, and ABMS. Examine the credentials, advantages, and health insurance claims background. Once you’ve gathered and reviewed these papers, you can present them to facility administration, who will decide which particular privileges to give to the provider.
This information is crucial for the credentialing process. Other alternatives include Credentialing software. The ideal credentialing software saves data and can include features that allow your credentialing procedure to be more straightforward and effective. Outsourcing. Is your human resources department overburdened with medical credentialing services? Using a medical credentialing service or outsourcing may reduce time and dollars.
5. Complete the Council for Affordable Quality Healthcare (CAQH)
Several large medical insurers mandate partner clinics to register for CAQH accreditation. 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. Any correct info must be accurate to ensure CAQH clearance. Be ready to re-attest following submitting your initial application. After implementing calendar reminders and assigning a dedicated staff member to manage CAQH updates, they avoided future delays.
6. Gather Information
A healthcare facility or health insurance plan asks the provider for information on his or her background, licenses, education, etc. The provider may submit the information in a questionnaire through email or software. Sometimes, the healthcare facility or insurance company works with a third-party company—called a credentials verification organization (CVO)—that works with the provider to gather and verify information. Organizations often hire CVOs to allow for more efficient credentialing.
7. Check the Information
Often, the facility or insurance company will do the background work. They will directly correspond with licensing agencies, medical schools, and other entities to verify the provider’s information. In other cases, the facility or insurance company may use credentialing software to continuously check information that licensing agencies and other entities make available online. The CVO may also run verification checks. Many healthcare organizations use collaboration and work management platforms to help them organize and record provider information and get automatic updates when specific credentials expire or need to be re-checked.
8. Award the Provider with Credentials
After the organization verifies all required credentials and finds no negative issues, the healthcare facility awards credentials to the provider. After the health insurance company completes a similar process, it can approve the provider as an in-network provider. The insurance company will pay the provider to treat insurance patients.
9. Keep Track
Don’t wait five or six months for an insurance provider to contact you. Develop connections with central insurance personnel. Developing a good working relationship with management, executive associates, and other staff members could help guarantee that applications are processed quickly. Instead of following up through email to boost response chances, use the phone. If you notice that more info is necessary, compile and check all documentation as quickly as possible.
Difference Between Credentialing and Enrollment in Medical Billing
Credentialing is the process of verifying the skills, training, and education of healthcare providers. It involves checking their background and qualifications before they can deliver care services. Credentialing helps to ensure providers have the required qualifications to offer safe, effective care.
Healthcare facilities or organizations typically conduct credentialing to verify a provider’s qualifications before hiring them or granting them privileges to practice at their facility. Insurance companies can also conduct Credentialing to verify a provider’s qualifications before allowing them to join their network.
This process helps ensure that only qualified providers can bill the insurance organization for patient care services. Credentialing involves contacting “primary sources” to verify a provider’s education, training, and licensure. For example, if a physician is credentialed, the process would involve contacting the medical school they graduated from, the training facility where they completed their residency, and the state medical board that issued their medical license.
Each of these organizations would have information about the physician that could be reviewed and compared to what the physician reported to the insurance company. Credentialing aims to ensure that this information matches and that the physician is qualified to deliver the patient’s care.
Enrollment Explained
Enrollment refers to requesting participation as a provider in a health insurance network. It involves requesting participation, completing credentialing, submitting supporting documents, and signing the contract. Enrollment also validates a provider in a public health plan and approves billing the agency for services rendered.
Types of Payer Enrollment in Healthcare
The enrollment processes for different payers vary. Furthermore, different enrollment processes can be used for new medical staff and when medical practices apply for staff members to Medicare. Different types of enrollment have varying institutional references. For instance, CMS is the typical go-to resource for enrolling a practice into a Medicare program—the same as commercial payer enrollments.
Classic Steps of Payer Enrollment in Healthcare
The National Association of Medical Staff Services offers thorough documentation on a payer’s enrollment steps in an ideal setting – the steps are as follows:
- Requesting for enrollment
- Completing the plan’s credentialing
- Submitting copies of licenses
- Signing contracts
Steps unique to contractors will include additional requirements where the individual payer has adjusted to their enrollment plan.
Key Differences Between Medical Credentialing and Payer Enrollment
The payer enrollment or provider enrollment credentials apply to an insurance panel. On the other hand, medical credentialing is a repository of information for verifying the valid status of a healthcare practice and all of its members. The medical credentialing process must be completed before an organization or provider can enroll with or bill an insurance carrier.
Interrelation of Credentialing and Provider Enrollment in Healthcare
Physician credentialing and provider enrollment are two critical processes for every healthcare organization. While both seem unrelated, the two processes are interrelated. Provider enrollment is the enrollment of healthcare providers with private health and government insurers. On the other hand, physician credentialing is verifying a physician’s credentials and privileges to practice at a healthcare facility. One essential requirement for a provider’s enrollment in healthcare is proof of physician credentialing. In other words, a healthcare practitioner cannot enroll with an insurer until and unless they undergo credentialing. Insurers must verify that a particular provider is qualified to offer care before they can start billing them for care services.
Similarly, most healthcare facilities will only grant physician privileges if they properly enroll with the facility. The provider typically does enrollments; however, credentialing is usually done by the health insurance company. Again, there are some cases where different parties complete the two processes. For instance, if a provider is credentialed through CMS, they must submit an enrollment application to CMS.
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Book a Call to Learn More About Our Provider Credentialing Services
Credentialing verifies that healthcare providers have the qualifications and training to deliver patient care. This process is crucial for patient safety and quality of care. Healthcare organizations must verify that all medical staff members have the proper licenses, certifications, and education to perform their jobs.
Not only does this process help protect patients and ensure they receive safe care, but it’s also essential for healthcare organizations to remain compliant with industry regulations and avoid penalties. Credentialing helps healthcare organizations maintain accreditation status with industry regulators, such as The Joint Commission (TJC) and the Centers for Medicare & Medicaid Services (CMS).
Types of Credentialing in Healthcare: What’s the Difference?
There are different types of credentialing in healthcare, including primary source verification, payer credentialing, and re-credentialing. Understanding the differences between each type of credentialing can help your organization stay organized and eliminate costly delays in the revenue cycle.
Primary Source Verification
When a healthcare organization receives a provider’s application for credentialing, it will conduct primary source verification to validate the information reported on the application. This process involves verifying a provider’s professional qualifications, education, training, and experience by contacting the issuing sources rather than taking the information reported by the applicant at face value. For instance, if a provider reports on their application that they completed a residency program, the organization will contact the program directly to ensure the accuracy of this information before proceeding with the credentialing process.
Payer Credentialing
Payer credentialing (or insurance credentialing) is getting approved by insurance companies to bill for services rendered to policyholders. This type of credentialing verifies a provider’s qualifications to ensure they meet the standards set by the insurance organization. Payer credentialing is separate from hospital and facility credentialing and often takes longer. While some information reviewed during the process may overlap, obtaining payer approval is critical to the revenue cycle. It must be completed before a provider can see patients covered by a particular insurance policy.
Re-Credentialing
Re-credentialing verifies a provider’s qualifications after being granted privileges or approval to bill for services. This credentialing occurs regularly, typically every two to three years, to ensure that healthcare providers maintain their licenses and certifications and that no adverse events have occurred since they were last reviewed. Re-credentialing helps healthcare organizations identify potential issues with a provider’s ability to deliver safe patient care before adversely affecting patients or the organization.
Azulity: The Credentialing and Privileging Game Changer
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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