A Medical Credentialing Buyer's Guide

In the ever-evolving landscape of healthcare, the importance of proper medical credentialing cannot be overstated. Understanding the intricacies of medical credentialing is critical for assuring compliance, maintaining quality standards, and improving the operational efficiency of your healthcare services. Whether you are a medical practitioner, a healthcare administrator, or a member of a medical group, this guide is for you. 

What is Medical Credentialing? 

Medical credentialing is the process of verifying the qualifications, experience, and professional standing of medical practitioners. This process is completed for two reasons: 

Hospital/Medical Clinics

•  A medical provider needs to be credentialed in order to legally work at a hospital and treat patients. This credentialing process is usually done by the hospital. Independent clinics and providers will also still require the same credentialing that hospitals go through. 

Insurance  

• A medical provider must be credentialed with the insurance provider to receive payment from insurance providers. There are various types of credentialing within insurance but suffice to say that if you want to receive payment, you’ll need to be verified with specific insurance providers.   

Credentialing involves a thorough review of a practitioner’s educational background, residency, licenses, certifications, and any other relevant training. This information is relevant for almost any type of medical credentialing. 

What are Medical Credentialing Services? 

Medical credentialing services are experts at carrying out this thorough verification procedure. Medical credentialing services can be their own standalone companies but can often be paired with medical billing services as well because the two are so closely interlinked. These services make sure that all medical providers are credentialed properly and up to date with industry standards. Medical credentialing services can help you with: 

• Initial credentialing: The first time a provider needs to go through the credentialing process. 
• Re-credentialing: Around every three years a medical provider must go through the process again to make sure their credentials are up to date. 
• License Renewal: Providers will have certifications and other verifications that need to be renewed and verified. A medical credentialing service can help with this as well. 

Common Medical Credentialing Problems 

There are some common challenges when it comes to medical credentialing. If you choose to do this process alone, you could end up facing some of these problems

Delays in the Credentialing Process 

The length of time required to finish the medical credentialing process is one of the biggest problems. Incomplete applications, sluggish primary source answers, or backlogs at credentialing services can all cause delays. These delays may cause practitioners’ start dates to be delayed and perhaps result in income losses for healthcare facilities. 

Inaccuracies in Credentialing Information 

When it comes to credentialing, accuracy is crucial. Errors in employment histories, school transcripts, or licenses can seriously impair compliance and endanger patient safety. It might be difficult to ensure accuracy, particularly when working with a large number of practitioners or antiquated information systems. 

Compliance Issues 

Medical credentialing must abide by a number of laws, such as HIPAA and accreditation body guidelines. Failure to comply may lead to financial penalties, legal repercussions, and reputational harm. 

Challenges in Maintaining Up-to-Date Credentials 

Healthcare providers must keep their credentials up to date, which requires regular upgrades and re-credentialing. This continual process can be taxing on healthcare facilities, particularly those lacking specialized credentialing resources. 

Responsibilities of a Medical Credentialing Provider 

In-Depth Verification of Credentials 

Beyond the basics, they look into a practitioner’s background, including any disciplinary actions, malpractice claims, or other red flags that could jeopardize their position. 

Gathering Primary Source Verification 

They contact universities, licensing bodies, and past companies directly to verify credentials, ensuring that the information is not only correct but also up to date. 

Credentialing for Different Specialties 

Understanding the precise requirements for distinct medical specialties and subspecialties, as well as ensuring that practitioners meet these requirements. 

Monitoring Legal Compliance 

Keeping up with evolving healthcare rules and regulations at the federal, state, and municipal levels, as well as ensuring that practitioners follow these legal obligations. 

Medicare/Medicaid Enrollment 

Medical credentialing services can help you gain credentialing with government services like Medicare/Medicaid.  

Provider Enrollment Services 

Assisting healthcare providers with registering in various insurance networks, including negotiating with insurance companies and executing the relevant paperwork. 

Ongoing Credential Updates and Re-credentialing 

Maintaining compliance and guaranteeing uninterrupted service delivery requires regularly updating credentials and managing the re-credentialing process. 

Technology Integration: 

Implementing and managing credentialing software solutions that integrate with other systems used by healthcare facilities, such as electronic health records (EHRs). 

Benefits of Using a Medical Credentialing Provider 

Using a medical credentialing service can be beneficial for multiple reasons. Here are just some of the most important things that you can take advantage of. 

Streamlining the Credentialing Process 

These providers have processes and expertise in place to manage the credentialing process efficiently, saving time and effort when compared to managing it in-house when you are a small clinic. You can also focus your effort on more important tasks that can improve your patient experience. 

Reducing Administrative Burden 

Healthcare facilities can focus more on patient care and other essential tasks by outsourcing credentialing, leaving the complex and time-consuming process of credentialing to specialists. 

Enhancing Accuracy and Compliance 

Professional credentialing services are skilled in ensuring high accuracy in their verification processes while also adhering to all relevant regulations, lowering the chance of errors and non-compliance. 

Improving Provider Enrollment and Reimbursement Times 

Efficient credentialing speeds up the process of enrolling new providers and facilitates quicker reimbursements from insurance companies. 

Scalability 

As your clinic grows, your credentialing will need to grow as you take on more providers. A medical credentialing service can help you scale your practice without stumbling.  

Enhanced Provider and Patient Confidence 

Accurate and thorough credentialing processes enhance the trust of both healthcare providers and patients in the quality and reliability of the healthcare services offered. 

Reasons to Outsource Medical Credentialing 

While outsourcing your medical credentialing services doesn’t work for everyone, there are some specific reasons you should employ these services.  

• Outsourcing can be more cost-effective than hiring an in-house team 
• You’ll have experts to help you in the medical credentialing field 
• Easier to keep up with changes in credentialing agencies 
• Help keep your focus on treating patients or growing your practice 
• Reduce administrative workload 
• Better turnaround times for medical credentialing 
• Access to better technology and software 
• And more! 

Pricing of Medical Credentialing Services 

According to 99MGMT, you should expect to spend around $2000-$3000 for credentialing services per year. However, this can fluctuate depending on the number of providers, specialty, and other factors. Most likely you’ll be given a custom quote based on your healthcare facility’s needs. 

Ready to outsource your medical credentialing service?