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About Blast Credentialing Services
About Blast Credentialing Services
At Blast Credentialing, we only work with physicians and health professionals that we believe are trustworthy, compassionate, and respectful and uphold our code of conduct in their daily work. For that reason, our credentialing process is rigorous and thorough. It extends from pre-hiring to consistent monitoring of employees’ and practitioners’ procedures, licensing, and continuing education and training. Our patients place their lives in the hands of Hartford HealthCare staff every day, and we do everything in our power to deserve that trust and inspire confidence in our abilities to care and treat.
While many may think of Medical Credentialing as a modern concept, it has been a part of physicians’ careers since long before the middle ages. By the medieval period, the credentialing process was becoming more involved. In 13th century Paris, the formation of the College de Saint Come split the barber surgeons (surgeons of the long robe) from lay barbers (barbers of the short robe). To become a member of the College, and thus a surgeon of the long robe, one had to meet specific conditions for admission and pass an examination given by a panel of surgeons.
Modern day credentialing is far more complex and the process more error prone. We break down the basics of medical credentialing, the major players, benefits, best practices, most common issues and more. Read on to discover the convoluted, yet crucial, world of medical credentialing.
Medical Credentialing — also known as provider or physician credentialing — is an elaborate process that examines and reviews the health care provider’s qualifications and career experience including education, medical certification, training, licenses held and any specialty certificates to determine if clinical privileges to practice in a particular place can be granted. It must be completed upon the hire or enrollment of a new provider. It must be repeated regularly afterwards in accordance with the standards set forth by regulatory and accreditation organizations such as the National Committee for Quality Assurance (NCQA) and The Joint Commission (TJC).
Medical Provider Credentialing may vary state-by-state, however, it usually involves three different processes:
Physician credentialing and privileging is crucial for overall patient safety as well as required by the government and accreditation agencies. It is also crucial to both developing a practice with a high level of patient care and receiving insurance reimbursement. This process forms the basis of how insurance providers and states determine which providers meet their specific requirements.
Medical provider credentialing involves a review process of many different areas of the medical professional’s career, including but not limited to:
Before signing up for the credentialing review, it is important to know what information is required from any medical professional wishing to complete the process. The following information is needed to fill out the Provider Application credentialing paperwork completely.
However, credentialing laws and regulations vary between states. Make sure to research any state-specific rules which may apply to the credentialing application process. To get more specific, the types of verification required for credentialing may include the following:
There are several organizations which handle the necessary information for primary credentialing. As aforementioned, each state has its own licensing program rules, often broken down further into those for doctors and those for nurses. The following are a few of those crucial organizations which handle credentialing information:
After applying, another set of massive players in provider credentialing are the U.S. health insurance companies. Partnering with insurance companies is a necessary process for any medical office. Physicians and other professionals must provide a list of verifications to insurance carriers, including Medicare and Medicaid, in order to be eligible for reimbursable expenses.
Due to rising levels of complexity, many providers are looking at outsourcing as a response. There are many benefits of outsourcing credentialing and enrollment, such as:
The credentialing process can take anywhere from 90 to 150 days, depending on the state requirements. Due to the extended processing time, make sure to leave plenty of time – at least four months — to complete the credentialing application process.
As mentioned, the physician credentialing process can take quite a long time, even more so for medical professionals who are not adequately prepared. Streamline the process with these five best practices.
Staying current with relevant organizations, like the Council for Affordable Quality Healthcare (CAQH) can make things a little simpler. According to an article published by Physicians Practice, “most payers in the nation have adopted [the CAQH] program.” The piece also notes that both new and veteran physicians who update their CAQH regularly find both credentialing and re-credentialing easier.
The credentialing process can be difficult to complete correctly, not to mention stressful. Provide potential staff with the information and tools which would not only make their application process easier but also let them know you support their efforts (see below).
Have medical staff start the application process as soon as possible. Credentialing can take upward of four months so have medical staff start the process at least four months before their expected work start date, if possible. An article by Physicians Practice notes that “as payers have merged and supersized, a practice’s ability to…expedite an application has shrunk,” which means that you need to give yourself ample time to get through the application process.
In order to avoid having a new provider not yet credentialed, have their start date tied to their credentialing paperwork submission date. For instance, have them start no sooner than four months after the submit. As a Physicians Practice article notes, “it’s better for the practice in the short run: it isn’t scheduling around payers with which the new physician is not credentialed. And it’s better for the new physician, whose schedule can be filled sooner and practice grow faster.”
Because the process is often so convoluted, it is ideal to keep all medical staff members’ application status info in one place, for easy reference and updating. This allows for any readjustments to be made in order to comply with the application processing.
Filling out all the application forms can be daunting. To make the application process more transparent for them, consider including the following in a Medical Credentialing Packet:
Helping medical staff or candidates with the process, by providing the right tools and information to make the journey smoother, will both support and help them to complete the process.
Of course, readying and completing the application is just one of the steps in the entire process. It also needs to be checked extensively for any errors. The following are some common errors seen with Credentialing:
This includes any missing supporting documentation, required training or filling in of education or work gaps.
This includes any part of the application which was not completed, including blank areas, missing support documentation and incorrect info.
This occurs when some institutions require further postgraduate training or a completion of residency for credentialing criteria, but the applicant has not fulfilled the request.
A lack of organization can cost an office in appeals and lost reimbursements. Instead, consider outsourcing the credentialing process to a professional in order to keep the office on schedule and ensure no credentialing expiries occur.
There may be more credentialing requirements depending on which state your practice is in. Make sure to check for reciprocity agreements with the state and payer organizations when taking on a physician from another state.
Many offices aim for the minimum credentialing process time. However, many payers actually take much longer, around five to six months. To be extra sure, plan for the longer processing time while hoping for the minimum.
What: Re-credentialing requires a provider to repeat the credentialing process.
How: Providers will get a letter notifying them they are up for re-credentialing.
Why: Re-credentialing allows for a physician’s skills and history to be constantly reevaluated, hopefully minimizing any continuing to practice poorly.
When: If providers don’t complete their re-credentialing within the deadline, their credentials are suspended until the process is completed and approved. During that period of suspension, they may not practice medicine.
Who: For example, boards often require re-credentialing every three years, according to state or federal requirements.
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