Source of Delays in the Credentialing Process:

The credentialing process may get further delayed due to few primary causes. They are as follows:

  1. Poor response or planning: Many times the response from new physicians or even credentialed physicians for our requests of credentialing documents/certificates is poor. The poor response or planning from physician will hinder us on early submission of requests.
  2. Require involvement from new provider: When we hire a new provider, we must make sure he or she knows they are responsible for completing the credentialing process for all the payers. They should not think it as an inconvenience or offensive to require them to share necessary credentialing documents; because it is their absolute responsibility. In order for the practice to be paid for their professional services, they must go through the credentialing and contracting process with each payer. Best practice would be to link a provider start date to completing primary payer credentialing.
  3. Pay attention to the details: With such a lengthy process ahead of us, we should not delay our implementation by submitting credentialing applications with missing or incomplete information. Here are some of the most common errors found on payer enrollment applications:

Incomplete work history – Physician must include his/her current practice and all prior professional work history since graduating medical school and history must include mm/yy format on all start/end dates;

• Malpractice insurance – Physician must include current policy.

• Hospital privileges – He/she must have admitting privileges to an in-network hospital in order to participate with a health plan. If they do not, then will need to have an admitting arrangement in writing with another in-network physician who will attest to an agreement to admit any of their patients that require in-patient services; or to have agreement with hospitalist group to admit patients.

• Covering colleagues – New physicians are responsible for providing coverage for patients 24/7 and will need to disclose colleagues who cover for them when they are away. This is particularly important for solo practitioners;

• Attestations – Should fully answer all yes/no questions on each application and provide complete details for response when necessary.

• Errors/Mistakes – Typo, capturing wrong information on the application etc., by credentialing specialists will delay the process. Each error/mistake and subsequent clarification or correction sought by the payer will delay the process by weeks and sometimes months.

  1. Stay current with CAQH: A most current CAQH profile is an important part of commercial insurance credentialing. So we must make certain that physician’s CAQH profile is current with all personal details, attestations, signature pages, and required documents. A majority of commercial payers utilize CAQH to retrieve the bulk of credentialing information. An incomplete profile will cause a delay in the process.
  2. Know the key payers: Know which payers represent 80% of business so that we can prioritize credentialing to complete those payer processes first. We can selectively schedule patients for our new provider based on which payers have contracted until the new provider is fully credentialed.
  3. Frequent Follow up:
    • Insurance companies often have the habit of losing applications or misplacing them elsewhere. Follow up process is very essential to keep our application safe and take it further for next stage of processing.
    • If application is stuck for more weeks, it automatically expires and gets rejected. So, credentialing specialists will have to do relentless follow up with insurance by calls and/or emails.
    • Frequent follow ups must be there to check up the application status.
    • Use of credentialing software will help us organize, track, follow up and complete the process effectively.
    Credentialing is a tedious process. If we are not fully prepared with all necessary information to complete the process on first submission, we will cause delays in the process. It is a best practice to only begin the process with payers after we have compiled all information typically required during the payer credentialing process.

Gain Hospital Privileges

In addition to insurance credentialing, we may be asked to enroll a provider with local hospitals, which is called gaining hospital privileges. This process also involves a lot of paperwork. After hospital receives the application, the credentialing/privileging department usually presents the provider to the hospital board for approval. Once hospital grants a provider privileges, the provider will be able to admit and manage patients in the hospital.