Insurance Credentialing Services

Not so long ago, healthcare professionals considered credentialing and contracting with insurance companies to be optional for building their practice. Compared to previous years, more patients have some type of a health insurance coverage, and a very small percentage of that patient population can afford paying the high out-of-pocket expenses for services from a provider that is not in network with their insurance carrier.

Simultaneously, insurance companies became inundated with network enrollment applications resulting in insurance networks becoming “closed” or just being selective about which providers they are adding. Due to that fact, the process necessary to become an in-network provider is getting more difficult every day.

What is Credentialing? It is a process used to evaluate the qualifications and practice history of a physician. This process includes a review of a physician's completed education, training, residency, licenses and certifications issued by a board in the physician’s area of specialty. This process is conducted before the physician is permitted to join the network. Once the physician and the practice are invited to accept an in-network status, the insurance company issues the contract which under certain circumstances can be negotiated for more favorable terms.

What is Re-Credentialing? As part of the contract agreement, the insurance companycontacts the provider to review providers' and practices’ credentials on an ongoing basis, following standards established bystates, regulatory bodies and accrediting organizations, such as the National Committee forQuality Assurance (NCQA).

On average, the initial credentialing process may take insurance company 90-120 business days, however on rare occasions it may take well over one year. Major insurance companies have reported to perform credentialing on close to 150,000 physicians annually.

What does the typicalinsurance credentialing unit process involve?

Insurance Credentialing Services :

1. The insurance credentialing unit gathers the information about a physician’s background and qualifications through a formal applicationprocess followed by:

• Checking the background information

• Checking the information against reliable sources, including the National Practitioner Data Bankand the American Board of Medical Specialties

·         Some of the specific information gathered includes, and is accepted through a signed document from the doctor that states the information is accurate and correct.:

Provider name and office location: This information is self-reported at least every three years or more often,according to state or federal requirements on the application.

Provider gender: This information (male, female) is self-reported at least every three years or more often,according to state or federal requirements on the application.

Specialty (-ies): This is the doctor’s special field of practice or expertise. If the provider has contracted with the insurer to provide services in more than one specialty, all will be listed. The credentialing unit checks thepractitioner’s highest level of training in his/her specialty and checks board certification status through primarysource verification. This is the process of confirming with the certifying board and/or facility where the physician completed residency training.

Patient age focus: When available, the provider directory will display information about whether the provider has a patientage specialization.

Languages spoken: This information includes the languages that the practitioner speaks.

Hospital affiliation: This is a listing of the hospitals where the provider has privileges to admit patients requiring hospital care. Thepractitioner’s hospital affiliations are checked by contacting hospitals to verify the information at least everythree years or more often, if required by state or federal regulations.

Medical group affiliation: This is a listing of the group practice that the practitioner is part of (whenapplicable).

Board certification: When a physician is board certified, it means that he/she has applied for and been awardedcertification from the American Board of Medical Specialties, American Osteopathic Association or otherrecognized boards, depending on the specialty. To become board certified, a physician must:

• Graduate from an accredited professional school

• Complete a specific type and length of training in a specialty

• Practice for a specified amount of time in that specialty

• Pass an examination given by the professional specialty board

Board certification is a voluntary process. The reported specialty board certification of the practitioner ischecked before contracting and at least every three years or more oftenthrough one of the following primary sources:

• American Medical Association

• American Board of Medical Specialties

• American Osteopathic Association Physician Profile Report

• American Board of Podiatric Surgery

• American Board of Podiatric Orthopedics and Primary Podiatric Medicine

• American Board of Lower Extremity Surgery, if applicable

Office status: This indicates whether or not a physician is accepting new patients. Physiciansare also required to notify the insurance company of updatesbetween credentialing cycles, in order to submit claims with correct address where the services were rendered, as well as, for the provider directory being updated with new information on payer’s protocol driven intervals.

 2. The credentialing unit will contact:

• Any state where the physician reports an active medical license and sees the patients

• Schools and hospital programs, to be sure the physician’s training is complete and accepted by thespecialty board.

• The National Technical Information Service, Drug Enforcement Agency or Controlled

Substance Registration, as confirmation that the physician is authorized to write prescriptions

• Medicare/Medicaid, to be sure the physician is not banned from caring for Medicare/Medicaidpatients

3. The credentialing unit will review physician’s:

• Personal history, to determine if any disciplinary actions have been taken

• Malpractice insurance, to confirm active coverage

• Malpractice claims history

• Hospital privileges, to determine if privileges have been lost or limited

• Work history and employment background

4. The credentialing unit submits all gathered and verified information to their Credentialing and Performance Committee, to make a final determination whether ornot the physician should be included as participating in the network.

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