Q. What is credentialing?

A. It is a process by which insurance carriers and hospitals verify the credentials of the medical provider. This includes verification of licenses, verification of malpractice insurance, verification of college degrees and background checks to disclose any felonies or criminal activity.

Q. Why is credentialing important? Who is it important to?

A. It is important to the provider to maintain his credibility with the insurance carriers and to hopefully receive a contract to participate in an insurance companies various programs. This is critical to a medical provider due to the fact that most of us want to see a doctor in our network as it creates a savings for us with our medical expenses. Most out of network benefits require us, the patient, to meet a deductible before any payments to the provider of services are made.

Q. How does credentialing help the medical provider?

A. Once a medical provider is credentialed and accepted into an insurance plan, their information is then posted in the provider directory. If a patient is looking for a medical provider in their network, they usually search by zip code. If a medical provider is not listed in that directory, the medical provider has missed the opportunity to get a new patient. Therefore, credentialing in a sense is a marketing tool as well.

Q. How does a medical provider go about the process of credentialing?

A. Credentialing is an extremely time consuming process and requires an individuals’ undivided attention. Current documents must be attached to a standard application which should be type written for legibility. Documents include licenses, diplomas, resumes, and declaration pages of the current malpractice. A cover letter should accompany the application and documents, introducing the provider to the carrier or hospital. Most providers use an outside service for this process.

Q. How long does it take to be credentialed?

A. Most carriers take from 90-180 days to complete their credentialing process. Once the provider is credentialed, the applications goes before a committee for final acceptance into an insurance plan.

Q. How will the provider know if they are accepted into a plan?

A. Most carriers inform the provider via letter along with a welcome packet of some type. Another method is to track your application which requires someone to contact the carrier every couple of weeks to check the status of the application.

All in all, credentialing is a very important part of the medical providers’ business.

Michele Graham
CEO and Owner of Professional Healthcare Management
Billing and Credentialing Service
41 years in the healthcare industry

http://www.phmnetwork.com
http://phmnetwork.blogspot.com

http://www.healthcarenewsonline.com

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Managed healthcare in today’s world seems to be leaning in favor of the insurance carriers, not the provider or patient. Patients are not allowed to see the doctor of their choice unless the doctor is in their network. Providers are not allowed to join those networks because the insurance carriers state their “panels” are full in the doctor’s geographic area.

If you search the provider directories posted on the internet, a lot of the doctors that are listed “in network” have moved to different areas or have even expired or have retired from practicing.

Many healthcare professionals are being turned away from network participation for no viable reason. Some states have a “any willing provider” law that allows any provider to belong to any provider network if they choose. Unfortunately, there are more states than not that do not embrace this law.

Outsourcing this task is extremely beneficial to a medical practice. The time spent in preparing complete credentialing packages is so critical to the acceptance of providers and most offices don’t have the time to prepare these packages. Also, more times than not, the providers do not send in the correct information needed to get him/her credentialed and in participating status with insurance carriers.

Providers that attempt to operate a cash practice are taking a huge risk. In today’s healthcare world, it is almost imperative that doctors are participating in medical insurance plans, for their businesses to survive.

Michele Graham-CEO and Owner of Professional Healthcare Management, offering credentialing and insurance billing to healthcare providers. Michele has 41 years in the healthcare industry.

http://www.phmnetwork.com

http://phmnetwork.blogerspot.com

http://www.healthcarenewsonline.com

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