A Provider Credentialing & Contracting Checklist
A credential provider gets an increased number of patients through referrals from
payers. Further, credentialing assures the patient that they are getting treated by a
credible provider. It also helps physicians expand their business. Physicians/providers
must credential themselves, i.e., enroll and attest with the payer’s network and get
authorized to provide services to patients who are members of the payer’s plans.
Steps to File Credentialing Applications accurately
A good provider application is the first step to success in the credentialing process. A
provider himself can fill this application, or he/she can outsource this process to an
experienced Credentialing specialist. An accurate application will consist of all details,
including:
- Copy of state license
- Copy of DEA
- Provider DOB and SSN
- NPI #
- Updated CV- work history
- NPPES logons
- CAQH logons
- Malpractice incidence details
- Copy of Degree/Diploma certificates
- Copy of Driving License
- Group Name
- GNPI & Tax id
- Practice and billing address along with Phone and Fax #
- Signed W9
Importance of CAQH database for Physicians
CAQH stands for “Council for Affordable Quality Healthcare.” It is an online database that
stores provider information. Providers grant access to their data to insurance companies
through CAQH, making acquiring provider information more manageable. Almost all of
the National Health Insurance Companies use CAQH, which makes it a prerequisite for
their enrollment process.
There are three steps to getting set up in CAQH.
Obtain your CAQH ID (within 2-3 business days)
- Set up your secure username and password
- Complete the online application and send in the required documentation
- Send your attestation for signature, which certifies the application
- Grant insurance companies access to your online application
Not having a completed, up-to-date CAQH application will delay your enrollment with the
insurance companies. Furthermore, this will prevent you from getting reimbursed for
your services.
Consistent follow-up with the payers
After submitting the provider credentialing application to the payers, the Provider or the
credentialing team should ensure that they follow-up once in 5 days. Frequent follow-ups
enable you to catch applications with errors or rejected applications faster and re-submit
them in a short span.
Payer Contracting
A successful Credentialing approval is followed by a process that associates the physician
with the payer’s network. This process is known as Payer Contracting. Typically, the
payer will share the standard reimbursement rates and the traditional plans such as
HMO, PPO, WC, and Auto insurance. While contracting, a provider should ensure that he/she:
- Is adopting an insurance plan that is suitable for his/her business
- Negotiates a fair reimbursement rate for the services provided
- Appeals to open the panels of the networks that are closed for new providers
Post Credentialing and Contracting
Importance of Maintaining Provider Data Insurance directory Submissions
Providers must keep their details and contact information updated in the provider
directory to provide accurate information to the patients. A provider should insist on
including these details while completing the insurance directory verification and edit the
information as & when required:
- Provider name and educational qualifications
- Practice Specialty with board certification details
- The legal business name that he/she has been practicing with currently
- The correct phone number for booking appointments or clarifying any other queries
Adding / Deleting providers for Provider groups:
A practice running a group facility with more than one physician should consistently
update any additions or deletions in the group for un-hindered reimbursements. The
practice administrator should report:
- Any addition of new Physicians / Mid-level providers to the provider group for addition to the contract as well as the insurance directory
- Any deletion of existing providers from the group for removal from the contract & the insurance directory
Maintaining Provider Information
The significance of maintaining provider information lies in ensuring that provider
information is updated as needed. A practice must ensure that all Provider’ information,
such as contracted payment terms, name, address, tax id number, and newly gained
certifications, is kept current. With medical technology advancing at rocket speed, healthcare facilities see no end to their exponential growth in size and capacity. While largely overlooked, the key to hospitals performing with quality care and professionalism is the rigorous behind-the scenes work of their medical staff, making physician credentialing to hospitals’ uninterrupted operations.
FAQs about insurance credentialing
Many healthcare providers have questions about the insurance credentialing process.
Taking time to review answers to these questions ensures clarity and understanding,
enabling providers to navigate the process more effectively and efficiently.
Every practice that wants to bill an insurance company needs to be credentialed. This
includes hospitals, clinics, physicians, chiropractors, dentists, physical therapists,
behavioral health therapists, occupational therapists, optometrists, and social workers.
There are 3 potential challenges that might arise during your credentialing process.
First, not all insurance providers within an area are open to additional medical professionals.
In some instances, the insurance company’s market research may indicate the market is at a saturation point regarding its services. If this happens, ask the representative if they know when that decision may change.
Additionally, share any information you have that the insurance company doesn’t, such as if you are taking over an existing practice and will acquire an established patient base that is accustomed to having their insurance accepted. This may influence a different decision.
Second, some companies require experience before contracting with a new physician.
This doesn’t apply to all companies and is less frequent than it used to be. Still, some indicate they want a medical professional to have anywhere from 6 months to 2 years of experience before they will include that healthcare provider in the credential process.
Third, many companies do not plan for enough time to complete the process.
Multiple websites and agencies suggest you need to plan 6 to 10 hours to gather your information to simply begin the credentialing process. Once you submit your packet to each insurance company, you will have to schedule time to follow up with those organizations, gather additional information they request, and keep your application process moving forward. Know that just because these are potential challenges, it is not a given that you’ll run into them.
Working with a health insurance brokerage company or insurance credentialing consultants can help navigate these challenges and ensure compliance with insurance policy and coinsurance requirements outlined in the contract.
First, not all insurance providers within an area are open to additional medical professionals.
In some instances, the insurance company’s market research may indicate the market is at a saturation point regarding its services. If this happens, ask the representative if they know when that decision may change.
Additionally, share any information you have that the insurance company doesn’t, such as if you are taking over an existing practice and will acquire an established patient base that is accustomed to having their insurance accepted. This may influence a different decision.
Second, some companies require experience before contracting with a new physician.
This doesn’t apply to all companies and is less frequent than it used to be. Still, some indicate they want a medical professional to have anywhere from 6 months to 2 years of experience before they will include that healthcare provider in the credential process.
Third, many companies do not plan for enough time to complete the process.
Multiple websites and agencies suggest you need to plan 6 to 10 hours to gather your information to simply begin the credentialing process. Once you submit your packet to each insurance company, you will have to schedule time to follow up with those organizations, gather additional information they request, and keep your application process moving forward. Know that just because these are potential challenges, it is not a given that you’ll run into them.
Working with a health insurance brokerage company or insurance credentialing consultants can help navigate these challenges and ensure compliance with insurance policy and coinsurance requirements outlined in the contract.
Healthcare providers will face challenges in joining insurer networks and receiving
reimbursement for services if they make mistakes during the insurance credentialing
process. For example, submitting credentialing applications that have incorrect or
missing information will cause approval delays.
Not thoroughly researching and understanding the specific requirements of each health insurance company can result in mismatched expectations and potential issues with insurance costs and reimbursement rates. Private health insurance companies often have their own unique sets of criteria, documentation requirements, and application procedures for credentialing healthcare providers. Not effectively communicating with insurance representatives or failing to respond promptly to inquiries can result in delays or denials.
Forgetting to renew licenses, certifications, or malpractice insurance can lead to credentialing lapses and difficulties in maintaining provider status with insurance companies. Unexpected insurance costs, reduced reimbursement rates, and unsavory clauses might emerge from insurance contracts that are not well-reviewed and understood.
Due to the plethora of moving pieces in this overall process, it is best to:
• Put reminders in your office’s electronic calendar 3 months before your credential expiration date
• Maintain files of all information gathered for each health insurance company, including all current certification information and subsequent renewals
• Make sure your electronic information is backed up so the critical information does not get lost and require you to rebuild it
Not thoroughly researching and understanding the specific requirements of each health insurance company can result in mismatched expectations and potential issues with insurance costs and reimbursement rates. Private health insurance companies often have their own unique sets of criteria, documentation requirements, and application procedures for credentialing healthcare providers. Not effectively communicating with insurance representatives or failing to respond promptly to inquiries can result in delays or denials.
Forgetting to renew licenses, certifications, or malpractice insurance can lead to credentialing lapses and difficulties in maintaining provider status with insurance companies. Unexpected insurance costs, reduced reimbursement rates, and unsavory clauses might emerge from insurance contracts that are not well-reviewed and understood.
Due to the plethora of moving pieces in this overall process, it is best to:
• Put reminders in your office’s electronic calendar 3 months before your credential expiration date
• Maintain files of all information gathered for each health insurance company, including all current certification information and subsequent renewals
• Make sure your electronic information is backed up so the critical information does not get lost and require you to rebuild it