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?
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.
For more details about Insurance Credentialing Services, Please visit at
www.elitemedbiz.com.
