Why Credentialing For Medical Providers Is Ongoing

With the arrival of a new doctor at your medical practice, fresh expertise and perspectives are brought into the fold. Your office can now expand, accommodating more patients and ensuring better access to healthcare in the community.


Yet behind the scenes, administrative gears churn, signaling the need for a critical process to take place before your practice can fully integrate this new addition: medical credentialing. 


While your healthcare organization may have already gone through the process of becoming credentialed, the process isn’t a one-time event. In fact, there are several instances that trigger the need for the medical credential process to take place once again, and a new physician on staff is just one of them.


Your medical practice is likely to experience several changes as it evolves, and some of these may warrant the need for revisiting the medical credentialing process.


When Medical Credentialing May Be Needed



While you may have gone through the medical credentialing processcredentialing for medical providers whenyour practice first opened, there are several reasons why you may need to do it again, including:


  • New Providers: New faces at your office may require new credentialing for medical providers. When hiring new healthcare providers, practices need to go through the physician credentialing process to ensure they meet the required standards and qualifications.
  • Insurance Participation: To accept payments from insurance companies, medical practices must be credentialed with those specific insurers. This ensures that you are eligible to provide services covered by patients’ insurance plans.
  • Facility Privileges: If your practice operates within a hospital or other medical facility, healthcare professionals may need to be credentialed by that facility to gain privileges for admitting patients, performing procedures or accessing resources.
  • Maintaining Accreditation: Medical practices may need to undergo credentialing to maintain accreditation from organizations such as the Joint Commission or the Accreditation Association for Ambulatory Health Care (AAAHC).
  • State Licensure: Some states require medical practices to undergo credentialing as part of the licensure process or to maintain licensure.
  • Credentialing Updates: Credentialing is an ongoing process, and providers must regularly update their credentials to reflect changes such as new certifications, licenses or malpractice insurance.
  • Network Participation: Joining provider networks or affiliating with healthcare systems often requires credentialing to ensure compliance with network standards and regulations.
  • Legal and Regulatory Compliance: If your practice chooses to accept Medicare and Medicaid as payments, you’ll need to comply with legal and regulatory requirements set forth by the Centers for Medicare & Medicaid Services (CMS).


Whether you’re becoming credentialed for the first time or going through the process again, it’s to your advantage to be prepared for the process. Let’s now take a look at what to expect.


What The Medical Credentialing Process Looks Like



What is credentialing in medical billing? Credentialing is the process of verifying and assessing the qualifications, experience and credentials of healthcare providers.


Agencies performing the credentialing process may verify items like:


  • Education and training from a medical school or other healthcare training institution
  • Medical licenses or history of licensing
  • Professional experience
  • Board certification
  • Malpractice insurance
  • Background checks
  • Peer references


When a change occurs at your medical practice, whether it involves a new doctor, privileges at a hospital or insurance, it’s important that you right away gather any required information needed to begin the credentialing process. 


In addition to gathering the above information, it’s a good idea to contact the appropriate credentialing organization to inquire about what is needed and when that information is required.


From there, you’ll:


  • Submit the applications and pay any applicable fees.
  • Wait for an approval or denial.
  • Resubmit the application with any deficiencies or incomplete information addressed if denied.


Keep in mind that you’ll also need to report any changes even after you’re credentialed. For example, any disciplinary actions, new certifications or changes in malpractice insurance should be reported.


Who Can Help With Medical Credentialing



Because medical credentialing is an ongoing process, it can be time-credentialing for medical providersconsuming for your medical staff. While you may want to focus solely on patient care, the fact is you have to set aside a significant amount of time to handle any administrative requirements, from billing and coding to medical credentialing.


An experienced medical billing and coding company that provides credentialing services can help you through this process. Whether you run a small practice or a large physician’s office, having medical billing services available to you can allow you to focus on patient care and managing your practice.


In addition to streamlining the credentialing process by gathering and organizing all the required documentation, medical billing companies will follow up with insurers to ensure you can begin participating in an insurance network as soon as possible.


High quality companies will also proactively track expiration dates, renewals and changes in provider information, saving you time and resources that you can instead allocate to patient care. 


In addition to medical credentialing services, medical billing companies can:


  • Streamline insurance claims processing
  • Maximize revenue cycle management
  • Provide coding audits and compliance reviews
  • Conduct reimbursement analysis
  • Offer patient billing and collections services
  • Provide financial reporting and analytics
  • Offer denial management services
  • Provide training and support for staff


With the right partner by your side, you can take the time to focus on your patients while feeling confident that any medical credentialing needs are being met.


8 Tips To Find Medical Credentialing Services



Finding the right medical credentialing services is crucial for ensuring a smooth and efficient process. Here are eight tips to help you find the best option for your practice:


  1. Research online. Start by conducting research online to identify medical credentialing service providers. Look for companies with experience in the healthcare industry and positive reviews from other medical practices.
  2. Ask for recommendations. Reach out to colleagues, peers or professional networks for recommendations. Word-of-mouth referrals can be invaluable in finding reliable credentialing services.
  3. Check credentials. Verify the credentials and certifications of the credentialing services providers you are considering. Ensure they have expertise in medical credentialing and compliance with industry standards.
  4. Evaluate services offered. Review the range of services offered by each provider. Look for comprehensive solutions that cover all aspects of the credentialing process, from initial applications to ongoing maintenance.
  5. Consider technology and support. Assess the technology platforms and support services offered by the credentialing services providers. Look for companies that have updated medical billing software programs and dedicated support staff to assist you throughout the process.
  6. Compare costs. Request quotes from multiple credentialing service providers and compare their pricing structures. Consider factors such as upfront fees, ongoing maintenance costs and any additional charges for extra services.
  7. Check references. Ask for references from past or current clients of the credentialing services providers. Contact these references to inquire about their experiences and satisfaction with the services provided.
  8. Review contracts carefully. Before signing any contracts, carefully review the terms and conditions of the agreement. Pay attention to cancellation policies, service level agreements and any clauses related to data security and confidentiality.


Before hiring a billing and coding company, it’s critical to ask the right questions. Our article, National Medical Billing Services: What Every Healthcare Provider Should Ask, provides the questions you should ask before you entrust your practice’s financial health to an external provider.


By following these steps and conducting thorough due diligence, you can find the right medical credentialing services provider to meet the needs of your practice.


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