6 Lessons Learned: Credentialing

Practice Credentialing and Provider Enrollment. Healthcare credentialing is the verification of academic, training and skills of a health practitioner. There are steps that are performed during the credentialing process. It includes verification of the medical school, verification of completion of training, check on training such as internship, residency and fellowship. For verification to be done, the health institution has to go to the primary source of this information. The state license board is contacted to confirm the issuance of the license. The licenses has to be checked whether it is active o there are restrictions applicable to it. They will have to contact the said medical school to verify the education credentials of the practitioner. The length of the verification process depends on how many items need to be verified and their complexity. The purpose of physician credentialing is to help health care entities to allow practitioners provide services in its campuses and for providers to participate in insurance networks.
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On the other hand, the provider enrollment is processed by which a service provider requests to participate in a health insurance plan. The procedure starts by application to participate in a network/plan, submitting documents for credentialing process, other documents submission, submitting a license to a carrier and signing a contract. There might be other document requirement and processes for various carriers. Several carriers trust CAQH as a central information. An up to date profile with CAQH s required for every physician to aid the enrollment process. The health carriers use the credentialing process to verify educational, licensing, training and other unique qualifications required for participation in a plan. The health carrier then offers a participating contract after they are through with verification.
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The processing time of enrollment depends on their payor. While some plans can be completed within 90 days; others will take up to 180 days. After the provider start the enrollment activity, he/she ought to follow up. This can be done using certified mail, emails, fax, documenting phone conversations with agents and others. To ease the process, some companies help healthcare service providers with the physician enrollment. The service provider only pays some fee to have this done. The client responsibility of application and following on the insurance companies is undertaken by the insurance firms. The benefits of working with these firms are that they save the physician on time. The physician also stands to befit from their daily experience working with the insurance firms. Physician credentialing and provider enrollment should not be a nightmare for a service provider after updating their profile with CAQH system and working with facilitating companies. one of the things physician should note is that they need to have clean record for this to work.