Medical credentialing is the process of checking a physician’s qualifications and referring to their references. Although important in delivering quality medical care, this process has become more complex and time-consuming.

Credentialing ensures that a physician has all the qualifications necessary to practice medicine. It gives hospitals, health maintenance organizations (HMOs), and other facilities information about a doctor’s history to judge whether they are suitable for the position.

The need for credentialing came about because of managed health care. As this type of care grew, payments were made based on how well doctors treated patients. By examining physicians’ backgrounds, their employers could ensure their staff were doing the best job possible. 

Keep reading to learn more about medical credentialing and the steps involved.

Steps in Medical Credentialing

The process of medical credentialing can take up to several months, and it is often a stressful and time-consuming task. For this reason, many health care providers outsource the process to credentialing specialists. 

However, with the right guidance, you can successfully handle your own credentialing without having to pay anyone or spend a lot of time on it. Here are the steps in the medical credentialing process:

1. Identify the Required Documents

The documents you need to collect will depend on the insurance companies or other entities applying for privileges. Most require proof of education, residency training and board certification, and a current CV and professional references.

2. Prioritize Insurers

Some insurers take longer than others to approve applications for privileges, so it is best to start with those first. If you have an agreement with one insurer, then apply there first. This will speed up your business operations and ensure that you get paid on time by that carrier once you start treating patients under their plan.

3. Check for Accurate Information

Before submitting your application, go through all of your credentials and ensure that all information provided therein is accurate. Even minor mistakes can result in denying privileges or a delay in approval.

4. Completing the CAQH

The Council must verify your information about Affordable Quality Healthcare (CAQH). This organization verifies your identity, education, training, and licenses. They also make sure you’re not on any exclusion lists.

5. Wait for Verification by Each Payer

Once you have submitted your application(s), the verification process will begin. The length of this process depends on each payer and is not uniform across all carriers. For instance, some payers require a full background check, fingerprinting, and a site visit before adding providers to their network. 

Other payers will do an education and work history check based on the information provided on the application.

The Key Takeaway

Ultimately, the medical credentialing process can be a challenge—but it doesn’t have to be. If you pay attention to all the important steps involved, you will greatly increase your chances of having an efficient experience with credentialing. 

And taking the time to understand the convoluted process before you even begin will help streamline everything once you begin the process. By paying attention to all of these factors, you can ensure that your medical credentialing is as easy and efficient as possible in the long run. Do you want your staff credentialed? Fill out the form below to contact our team.