Streamlined Credentialing Processes

We all know the importance of proper credentialing processes, but to clearly keep a grasp on the task as well as navigate and manage the potential impact on practice revenue can become a challenge that can quickly get out of control. Thankfully, there are some tips and tricks to the trade that can keep the process as seamless as possible, and keep it that way for good.

First and foremost, it is best for any practice to establish who will be responsible for these duties. Some practices have the luxury of a dedicated staff person who is employed to manage all aspects of the credentialing of the practice and providers, while other practices may have a limited employee pool to choose from that would encompass other job duties as well. Choosing THE person in the office with the best organizational skills is essential.

Maintaining a filing system for each provider is recommended, and can allow other staff members to easily access the information if the need should arise. Keeping an electronically based file system will enable you to easily view all the providers at once, and maintain all needed information with ease without the need to dig through a hard-copy folder and sift and sort through potentially outdated information. Each provider’s respective folder should at least contain the following information:

-Full name, address, date of birth, and birthplace
-Social Security number and Citizenship
-Diplomas
-DEA form
-State Licensure form
-Hospital affiliation information
-Past, present and pending lawsuit or adverse actions
-CAQH universal credentialing system login information

The next process is to gather all insurance information that the practice participates or wishes to participate in, and create sub-files under each provider for each of these insurance plans. If you do not already know, you must contact each plan to inquire about what is needed from you to get the process going. While this can become a time consuming task, it is imperative that it be done, as some plans may require one thing for one type of provider, and another provider may need something completely different depending on their current status with the company. This scenario is often seen for example with a provider who is changing practices vs a new provider who has never been credentialed before.

All correspondence as well as general notes detailing who has been contacted, what has been sent in, the date of contact or submission, etc. should be maintained under each respective sub-file. This will enable you to easily access this information in the event a credentialing application is taking longer than expected, and you need to do follow up calls to investigate. Representatives are much more attentive and willing to cooperate in your favor when you can give them a specific date and method that something was sent in or who and when you had a conversation regarding status for the application.

Timeframes for credentialing applications to be processed can be anywhere from three to six months, but can take longer. During that time, it is a good practice to contact the plans to follow up on the application process at each monthly mark to ensure that any and all hiccups can be caught and dealt with prior to it becoming a six month or more ordeal. Keeping meticulous documentation of these follow up calls is strongly encouraged.

Once the provider has been approved and contracted, keep the approval letters and contracts in the file system. A tickler system is helpful to remind you of when re-credentialing would be due, and is vital to maintaining participation with a plan. While most companies will send you documentation requesting the information needed to maintain participation, it is still the practices responsibility to comply and keep up with the re-credentialing process. As DEA’s and licenses come up for renewal for example, that information will need to be submitted in to maintain the provider’s status.

By taking these steps outlined above, a practice will not only be able to easily maintain their participation status with their patient’s insurance plans, they will also be able to ensure a healthy stream of revenue and avoid potential gaps in reimbursements.

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About the Author:

Amanda Raveaux

Amanda Raveaux, CPC, CPB, CPPM, CFPC, CH-CBS is a Medical Billing and Coding Supervisor, and has been in the billing and coding arena for 17 years. She has received her training from The American Academy of Professional Coders, and holds multiple certifications, as well as achieving certification for Community Health billing.