What is credentialing in medical billing company?

Credentialing is an important process of Healthcare Industry which is often overlooked. It is a rigorous verification process that grants the permission for the provider to render services and receive payment from the commercial insurance companies and government payers like Medicare and Medicaid. In this blog I have briefed what is credentialing in medical billing, its significance, and how it can be obtained. With this clear and actionable information healthcare professionals can easily understand the impact of credentialing how it affects their ability to provide care and receive proper payment.

What is Credentialing?

Credentialing in medical billing is the process to verify and ensure that healthcare providers are qualified, authorized, and meet the necessary standards to offer services and receive reimbursement from insurance companies. It is the step that grants them permission to join a payer's network and remain "in-network", so they can bill for services rendered.

According to the Council for Affordable Quality Healthcare (CAQH), credentialing involves assessing a provider’s education, training, licensure, certifications, and professional background to confirm compliance with industry standards

What does credentialing aim for?

Credentialing mainly aims to make sure that only qualified professionals are allowed to handle patients. It also mandates fulfilment of specific standards set by the regulatory bodies and insurance companies. This guarantees patient safety and facilitates timely payments for services rendered and also reduces the risk of malpractice and ensures high-quality care.

Types of Credentialing

Individual Provider Credentialing:This is to confirm that an individual healthcare professional possesses the necessary training, skills, and legal authority to practice their profession. This is the basis for all other types of credentialing. All physicians, nurse practitioners, dentists, and therapists are required to validate their credentials independently which enables them to bill separately under their National Provider Identifier (NPI).
Facility Credentialing: This type is applicable where practices with multiple providers are linked under a single group tax ID (TIN) and NPI (Type 2 - Organizational NPI) for billing purposes with insurance payers.
Re-Credentialing: It is a periodic process conducted typically every 2-3 years to re-verify that the providers continue to maintain the same compliances and standards with payers, hospitals, and regulatory bodies. This includes re-verifying their licenses, certifications, malpractice history, and any updates to their professional conduct.
Hospital Credentialing:This verification is done by the hospitals to check the credentials of the providers working under them, allowing them to treat patients within the hospital facility.
Payer Credentialing: In this process the insurance companies conduct verifications to ensure providers maintain compliance with network standards to become part of their "in-network" provider panel.

Why Credentialing Matters for Healthcare Providers?

The healthcare professionals will not be able to bill for their services without a proper credential, leading to significant financial challenges. Credentialing doesn’t just involve administrative paperwork but it is foundation to build patient trust, maintain financial stability, and legal compliance within the healthcare ecosystem.

The Credentialing Process: Step-by-Step

Step 1: Submitting the Application

Providers must submit a detailed application with all the following documents.

Educational certificate
Current and past state licenses
Board certifications
Malpractice Insurance
Professional references
National Provider Identifier (NPI)
CAQH profile (updated within 120 days)

Step 2: Primary Source Verification

The Insurance companies or the hospitals verifies and validates the submitted information directly with primary sources, such as medical schools or university, state licensing boards etc. This step legitimates the accuracy of the provider’s credentials.

Step 3: Verifying the backgrounds and references

A comprehensive background check is conducted to confirm the provider has no criminal history or disciplinary actions against them. This includes checking the Office of Inspector General (OIG) and System for Award Management (SAM) exclusion lists. They also check with the references from previous work settings.

Step 4: CAQH Profile Management

Most of the commercial payers rely on the Council for Affordable Quality Healthcare (CAQH) database for credentialing updates. So, providers must update their profile in their online portal with all necessary documents and authorize the payers to access them. These documents should be re-attested every 120 days to avoid suspension.

Step 5: Review by the Committee

A committee comprising of experienced healthcare professionals and hospital administrators, review the verified data and check them against the established standards. Based on their decisions the application will be and approved, delayed, or denied.

Step 6: Applying for Privileges (If Applicable)

Once credentialed, providers can apply for specific clinical privileges, to perform certain procedures. Privileging is based on the provider’s qualifications and the facility’s requirements.

Step 7: Recredentialing and continuous monitoring.

Providers must undergo the re-credential process for every 2-3 years to maintain their active status. They must actively monitor their profile on the CAQH data portal and update them.

Credentialing is a multi-step process and may take around 60-120 days or even longer. We at Shoreline Healthcare Technologies streamlines this process by managing all the step right from submitting the application, through verifications, and continuous follow-ups, saving providers time and resources. By partnering with us providers can focus on delivering quality care while we handle the complexities of credentialing, ensuring compliance and maximizing revenue.

FAQs

Q1. Can physicians practice without being credentialed?

No. It is necessary for all providers irrespective of their practise to get themselves credentialed for obtaining payments from insurance.

Q2. Is it enough for the provider to obtain credentialing once in his practice life?

No. Providers are required to apply and get re-credentials for every 2-3 years to keep them active for getting reimbursements.

Q3. Is credentialing and Enrollment are the same?

No. Credentialing is verifying the qualifications of the providers and checking them against certain standards. Whereas enrollment means getting into the insurers network so that they can bill for the service.

Q4. Can credentialing be outsourced?

Yes, you can outsource to specialized firms like Shoreline Healthcare Technologies who helps you to get through the entire process with ease.

Q5. How long does it take for credentialing?

It can take from 60-180 days depending upon the payers.

Q6. Is ShorelineMB the same as Shoreline Healthcare Technologies?

Yes, ShorelineMB.com is the official website of Shoreline Healthcare Technologies, a leading provider of medical billing and RCM services.

Sharanya Rajmohan

Content Writer

Sharanya brings clarity to the complexities of medical billing and healthcare regulations. With a knack for turning industry shifts into straightforward, actionable insights, her blogs help readers stay informed without the jargon.

Get your credentials today. For Assistance Contact Shoreline HealthCare Technologies.