CREDENTIALING PROCESS FOR NEW PHYSICIANS
Overview
New physicians/providers must credential themselves, i.e., enroll and attest with the Payer’s network and authorized to provide services to patients who are members of the Payer’s plans. The credentialing process validates that a physician meets standards for delivering clinical care, wherein the Payer verifies the physician’s education, license, experience, certifications, affiliations, malpractice, any adverse clinical occurrences, and training before contract is extended.
Payers may delay or refuse payments to physicians who are not credentialed and enrolled with them. These impact the financials of the practice negatively. Payer credentialing and enrollment services support physicians in:
- • Starting or joining a new practice
- • Switching from one physician practice group to another
- • Join or become affiliated to new groups or practices
Provider credentialing, the process of getting a physician or a provider affiliated with payers, is a critical step in the revenue cycle. The process enables patients to utilize their insurance cards to pay for medical services consumed and enables the provider to get reimbursed for the medical services provided. Therefore, it is important for healthcare providers to get enrolled and credentialed with maximum payers so that patients can use their insurance plans in your practice – failing to do so will result in the patient looking for competing providers who are enrolled with the health insurance companies they are subscribed to.
However, the process of getting a provider credentialed with a payer involves a lot of manual work in terms of completing the application forms, providing clarifications to questions from payers, and following up with them to close the credentialing request.
Credentialing Process Involves the Following:
- Preparation of checklist
- Send the checklist to physicians to collect all the data and documents required for credentialing process
- Store the documents on our secure path
- Save logins of insurance websites
- Identify top payers of the practice location
- Submit request with top payers identified
- Complete and submit a series of applications with each insurance payer
- Timely follow up with insurance payers on the providers’ credentialing application status
- Document all follow up calls and email communications in our the credentialing software
- Once credentialing is approved and contract is received, review the fee schedule before signing contract
- Negotiate if the rate is lower than 100% of Medicare fee schedule
- Review claims payment to see if payment is made according the fee schedule
What Essential Information is Required to Credential a Provider?
To begin the credentialing process, must gather the following information of new physicians. You will need to obtain his:
- Provider type — MD, DO, NP, PA, LCSW, etc.
- Curriculum Vitae (CV): a CV provides a full professional history and listing of academic credentials and with the explanation of any gaps. CV should be in MM/DD/YYYY format.
- Professional Liability Insurance Coverage (PLI/COI): Professional liability insurance is a type of business insurance that provides coverage for physicians to protect against claims of negligence from patients. It also helps protect physicians against claims that are not his/her fault. PLI should be of either individual coverage or add physician to the coverage of the group he/she is being affiliated.
- Current state licenses: This will inform you of whether Dr is licensed in the state where he plans to practice
- Drug Enforcement Administration (DEA) number: This will inform you if Dr can prescribe drugs in this state.
- Once Dr has his state license and DEA number, the next step is to go to the NPPES website to get his National Provider Identifier (NPI) number. Every provider who wants to bill needs to obtain an NPI number, which is a unique 10-digit number issued to U.S. healthcare providers by the Centers for Medicare & Medicaid Services (CMS).
Physicians will also need to obtain a Council for Affordable Quality Health (CAQH) number for billing purposes. CAQH allows insurance companies to use a single, uniform application for credentialing. Over 900 health plans, hospitals, and healthcare organizations use it and require practitioners to complete their CAQH profile before submitting their application.
We recommend having the provider fill out as much information as possible. After a provider has filled out as much information as they can about their personal, professional identification numbers, education, training, past work history and current practice, peer reference we can help fill up the rest of the fields and attest to the accuracy of the data. Insurance companies cannot begin credentialing process until the provider attests to their CAQH application. Note that the CAQH application requires attestation every four months, and we/physician will have to grant payer access to this information.
With this information in hand, we can start the process of credentialing new physician with top most payers.
How Long Does It Take to Credential a Provider?
The time it takes from start to finish varies. All of the verification of providers’ credentials takes time- exceedingly long time.
Under the most efficient circumstances, a physician can be credentialed to work at a hospital or credentialed and approved to be in-network for a health insurance company in 30 to 45 days. But more often especially with commercial insurance companies-it can take six months or more.
- Medicare
Medicare enrollment is one of the faster processes to complete. A sampling of few our Medicare provider enrollment applications processed reveals an average time to completion of 45 days. This average consist of the time that an application is submitted to a carrier until the time the carrier notifies of completion. The quickest turnaround for few physicians was 6 days (California – Noridian, Evan Marlowe MD) and the slowest turnaround was 73 days (California – Noridian, Martin Offenberger MD ).
It is important to note that the enrollment applications that were processed with quickest turn around time on first submission were submitted in PECOS and did not have any errors that required Medicare to request corrections or additional information.
A positive note about Medicare provider enrollment is that the effective date with Medicare will be the date the carrier receives your application or the effective date we put on the application, no matter how long it takes them to complete the process but the effective date we put on application could not be back dated more than 30 days from the date of submission. If physicians start seeing Medicare patients prior to application completion, he/she can back bill from the effective date once the application is completed.
- Commercial Carriers
The process with commercial carriers involves 1) submission of the carriers credentialing application or enrollment request form, 2) the carrier verifying all of all the healthcare provider’s credentials, 3) approval by the insurance carrier’s credentialing committee, and 4) mutual execution of a participating provider contract. The credentials verification process is completed in 60 – 90 days and the contracting phase completed in another 30 days for a total of 90 – 120 days from the time an insurance company receives the providers credentialing application. This timeline should be considered a general guideline for a standard credentialing process. Variances based on the type of provider, background, education and training, and other factors can have a impact on the total turnaround time of credentialing applications.
As we can see, there is a wide variation in the amount of time that commercial carriers take to complete the credentialing and contracting process. It’s always a good idea to assume that the process will take anywhere from 90 – 120 days for each plan application that we submit.
It is important to note that we will not receive in-network reimbursement from an insurance company until we have completed credentialing and contracting. We will only receive in-network reimbursement for claims with dates of service beginning with the effective date of the contract. Commercial plans do not typically back date effective dates of contracts.
| Payer | Average TAT | Maximum TAT | Comments |
| Aetna | 30 | 45 | Business days |
| BCBS-FL | 60 | 120 | Business days |
| Cigna | 45 | 90 | |
| Careplus | 45 | ||
| Humana | 90 | 120 | |
| Medicare | 30 | 45 | |
| Medicaid-FL | 14 | 60 | Business days |
| UHC | 45 | 90 | |
| Wellcare | 90 | 120 |
