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What is Provider Credentialing? Why is it Important?

More than ever, we hold healthcare professionals in high regard since some of them put their lives in danger to treat and save our loved ones. Doctors and nurses consistently placed among the occupations with the highest respect levels even before COVID-19. Patients put their faith in a system of checks and balances that enables service providers physicians and no physicians. To provide services and perform medical billing company procedures safely. Provider credentialing is a rigorous process that healthcare providers must go through in order to operate in or affiliate with a hospital or healthcare system and get payment for their services there.

What is Provider Credentialing?

Although we tend to conceive of the provider-patient interaction as being a one-to-one one, several administrative roles at hospitals share the burden of making sure the clinician provides safe, high-quality care. One aspect of this responsibility—verifying providers’ past and present competency levels to make sure they are fit for their roles—is the subject of provider credentialing.

The provider credentialing services requirement before an organization can award clinicians clinical privileges to carry out patient history and physical examinations. Open heart surgery, or write prescriptions for medications in a hospital setting.

Hospitals and healthcare facilities employ a multi-step procedure called provider credentialing to collect and confirm information on practitioners’ licenses to practice medicine. It is carried out on practitioners who are linked with the organization as well as those who are employed by it. Such as a community doctor who applies to join the hospital’s organize medical staff. In doctors’ private practices, credentials are rarely checked. Download this eBook that details the entire procedure for additional information.

In addition to hospitals/healthcare systems, managed care and insurance firms (i.e., payers—both private and public) also handle provider credentialing. They frequently work with a credentialing verification company (CVO).

How does provider credentialing operate?

A provider organization’s or payer’s credentialing department, as well as an internal or external CVO, completes the provider credentialing process in stages. Credentialing personnel:

  • Obtain data from a variety of sources, including the provider—a step that frequently requires intensive follow-up work.
  • Primary source verification (PSV) of the gathered information and documentation.
  • Analyze and spot any gaps, contradictions, or red/”pink” flags.
  • Make suggestions for credentialing, whether for consideration of clinical privileges or enrollment with a payer or payers.

Obtaining all required paperwork and certificates is part of the process of gathering provider information. After completing this stage, the data is verify for legitimacy and accuracy. Although it ultimately depends on whose regulatory and/or accreditation body(ies) the organization adheres. The specific data and papers that are collected are pretty uniform. The National Committee for Quality Assurance, The Joint Commission, The National Association for Healthcare Quality, DNV-GL, Individual State Oversight Bodies, The Centers for Medicare & Medicaid Services, Utilization Review Accreditation Commission, and many others are examples.

Verification of primary sources

Because secondary sources of information could contain inaccurate, untrustworthy, or biased information. It is imperative to consult the original source, or issuer, of the data or document. Think about how simple today’s technology allows healthcare professionals or fraudsters to falsify or exaggerate credentials in order to acquire patient access. PSV is therefore a crucial step in the credentialing process. If done incorrectly, the outcomes could include patient damage or death as well as negligent credentialing lawsuits costing millions of dollars. The typical PSV steps can be:

  • Verify the provider’s notarized government-issued identification as well as their OIG and criminal history records.
  • Examine the submission (and privilege requests if applicable).
  • Verify the provider’s training, residency, fellowship, and original source education.
  • Verify the provider’s status for board certification (if applicable).
  • Check the DEA, DEA registration for prohibited substances, and the state licensing.
  • Verify the existence of and history of claims for professional responsibility.
  • Run a search in the National Practitioner Data Bank.
  • Verify the provider’s prior employment.

If any one of these procedures is not carry out properly, provider credentialing may be refuse or delayed. An oversight throughout the procedure could cost the company or the candidate money, force them to restart the process, or even prevent them from getting the job they wanted. The ability of the provider organization to bill for provider services is also slow down by errors or ineffective provider credentialing. Which has a detrimental effect on cash flow in the revenue cycle. There are two simple strategies to avoid granting credentials to an unfit applicant. Making sure all information is validate and keeping a close eye out for gaps in the applicant’s background.

Who is in charge of credentialing?

As mentioned, both payers and provider groups do credentialing, however the two may use slightly different procedures.

Credentialing starts the process of obtaining information for hospitals and healthcare systems. That will eventually be utilize for clinical privilege delineation and enrolling physicians in payer panels so the organization can be reimburse for services.

Credentialing assists private payers (such as Cigna, Humana, and UnitedHealth) and public payers (such as the Centers for Medicare & Medicaid Services) in establishing and modifying the number of providers in their networks and figuring out their qualifications. The objectives are to reduce overall healthcare spending while ensuring that enrollees receive the healthcare services they have been promised.

However, providers also contribute to credentialing. Providers themselves go through a number of stages before applying for credentials at the healthcare organization(s) with which they plan to affiliate or begin practicing, including:

  • To prepare for their future career, finish your general medical education.
  • Complete fellowships or specialized courses to acquire the necessary technical skills for their vocation.
  • Obtain a license from their state or another relevant professional body.
  • Apply to the healthcare organization(s) you want to work for or affiliate with.

Whom does provider accreditation serve?

You might believe that the patient is the simple solution to the question of “Who is provider credentialing for?” However, the process’s main purpose is to ensure that everyone works in a secure environment of the highest caliber. Starting with provider credentialing and extending to colleague clinicians, all healthcare personnel, and patients, a safe, welcoming, and professional healthcare environment is provided. To support the development of this safe environment, providers must first go through the credentialing procedure.

Then, to assure continued competency, they are re-credentialed roughly every two years. Performance information on providers is gather periodically throughout the course of those two years. In order to influence future competence choices. Without the credentialing procedure, healthcare facilities put everyone’s safety in danger and risk getting into legal trouble.

Cloud computing facilitates distant credentialing tasks

Working from home and transferring data and documents using any electronic device from any location is a situation that will not go away. Cloud computing, also known as software as a service (SaaS), encrypts data and permits remote connectivity for any user, including service providers, with any level of rights provided. Does away with paper credentialing packets, and offers a productive way to share and reuse data that is already in the system.

Enrollment of payers and credentialing are integrating

Only lately has enrollment in hospitals become a function requiring administrative staff and resources on par with medical care. This was brought on by a number of circumstances. Such as the move toward employing healthcare professionals, hospital and health system closures, mergers, and consolidations. As well as the need to recover every dollar possible under value-based care models. Healthcare executives recognize a synergy between enrollment and credentialing as well as an opportunity for efficiency as its significance develops.

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