Why is Medical Professional Credentialing Important?

Credentialing is a term used to define the process used by the insurance networks, the hospitals and healthcare organizations to obtain and evaluate the documentation of a medical provider in regards to education, work history, training, regulatory compliance record, licensure, and malpractice history. It is very important to do this before the provider is allowed to participate in a given network or treat the sick at a medical facility or hospital.

Partnering with medical credentialing services is advisable for any medical office that wants to perform the process for its employees. Physicians and other professionals are required to provide a list of verifications asked for by the concerned insurance carriers for them to be eligible for the reimbursable expenses.

Types of Verification Credentialing Entail

Professional credentialing verifications usually vary by depending on the specifications needed by the specific medical facilities and insurance carriers. However, they may involve the following:

  • Board Certification
  • Education and Training
  • Hospital AffiliationProvider Enrollment Application
  • State License
  • DEA License
  • Malpractice Insurance Certificate

Consequences of Delays in Credentialing

The medical offices should always clearly indicate that a medical professional is prohibited from carrying out services without obtaining proper credentialing. The credentialing process normally may take as long as six months.

The main consequence of not obtaining proper credentialing is the loss of revenues. The insurance carriers are not going to reimburse any medical office the bills they make for professionals or services that the professionals provide if proper credentialing has not been done.

If for any reason a professional is given the go-ahead to offer services before the individual’s credentialing is completed, some of the insurance carriers normally backdate the reimbursement to cover all the services that were provided. However, a limited timeframe governs this. This entails taking a risk given that it could cost the medical office a big amount of dollars. The lost revenue can never be obtained from the insured or the concerned insurance payer.

Other Concerns Related to Obtaining Credentials

Nowadays, it has become increasingly difficult to obtain credentials due to the fact that many doctors are trying to perform their services in the same areas. This has led to competition for the limited spaces available on the insurance company panel. The panel refers to the list of approved credentialed doctors. However, in cases whereby the names on the list are too many, the insurance company is likely to deny more admission and credentials.

The safest, as well as the most financially viable option, is an individual submitting the provider enrollment packet plus any other required documentation and verifications as soon as possible. This will determine the success of the concerned medical office.

What is Required of the Provider or Medical Office

The medical provider or medical office is required to respond swiftly to any verification requests for the references for doctors or work history that need to be credentialed by the insurers to avoid holding the concerned parties back. For credentialing services and help, contact medical credentialing services.

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