What is Credentialing?

What is involved in third party payor credentialing?

Healthcare providers hear little about credentialing during medical education and residency programs. When discussing practice startups with physicians, many will share that finding the perfect location or the right office team is crucial. But when push comes to shove, the reality is that waiting for insurance credentialing approvals creates the most gridlock, and can be the most challenging aspect in getting a practice off the ground.

Credentialing is time consuming with unique networks elements. Understanding each payor’s distinct requirements, makes the process streamlined and can reduce the timelines. The summary below is intended to provide a realistic approach to the steps in the credentialing process.

When the exact demographics, tax ID and legal organization of your practice are known, payors can be notified and contract negotiations should begin. The credentialing time clock is set.

Credentialing involves completion of the application process and follow-up communications with each individual credentialing network. The process is rigorous and can take three to six months, depending on the third party payor, the current active status of the healthcare provider being credentialed, and the previous background of the provider.

Application paperwork is directed to each third party payer networks. Initially, the payor’s accreditation department scrutinizes the data item-by-item using National Committee for Quality Assurance (NCQA) standards. (This accrediting organization holds accountability standards for HMO’s, PPO’s and Managed Behavioral Healthcare Organizations (MBHO’s). Although NCQA credentialing standards are demanding, they have been well received and respected by the healthcare industry. Physician applications are reviewed according to these guidelines. Licensure, hospital privileges, DEA/CDS Certificates, Education, Residency, Board Certification, Malpractice Insurance and Claims History, Sanctions against Licensure, Medicare/Medicaid Sanctions and Ongoing Monitoring Sanctions are the primary checkpoints along the credentialing super highway. Managed care payors will also process physician credentialing paperwork through their own application protocols in tandem with NCQA standards. The payors review and contact references, medical schools, and malpractice carriers in an effort to assure a thorough background investigation prior to issuing approval at their monthly credentialing meeting.

CPMG Consulting brings a dependable, dedicated and compassionate team to every credentialing project. Their familiarity with payor representatives and experience working across the United States brings an added comfort to any new practice.