Step-By-Step Roadmap For Medical Credentialing Services

Step-By-Step Roadmap For Medical Credentialing Services

Medical credentialing process is one of the initial and most important processes for a healthcare provider in order to start their practice journey. This step is necessary because it is the gateway to receive reimbursement from insurance companies. Usually, a medical credentialing process is all about making sure the provider’s qualifications, education, training, and other necessary skills are according to the insurance company’s criteria for qualification. This qualification is important to ensure quality treatment is given to patients. In this article, you’ll learn a simple, step-by-step process on how to get credentialed as a doctor, you’ll also learn credentialing turnaround times, benefits of medical credentialing, etc. No matter if you are a new healthcare provider, or you are applying for re-credentialing, this article will help you understand the basic concepts of credentialing and a step-by-step roadmap for physician credentialing services.

What is Medical Credentialing?

Let’s start off with the basic definition of medical credentialing. It goes on by many terms like insurance credentialing or provider enrollment services, etc. As discussed above, it is a critical process that consists of initial verification of the healthcare provider. And this is to make sure they are qualified and capable enough to perform their medical duties professionally.
The checking includes the provider’s education, licensing, medical training, and work history. All this verification is compulsory to make sure they’re eligible to join insurance networks like United Healthcare, Medicare, etc., and can be recognized as in-network providers.
When providers are credentialed with particular insurance companies, it allows them to treat patients who have the same insurance company’s coverage. This also ensures that they maintain their quality treatment and ensure their patient’s safety.
Also, credentialing is not just limited to doctors and physicians. If you’re a nurse and wondering, “How can I get credentialed as a nurse?”, you can follow the same steps mentioned below.

Why is Healthcare Provider Credentialing Important?

The main reason for healthcare providers getting verified by insurance companies is to ensure they are qualified enough to provide the best treatments to their patients. This quality-assurance system is linked in such a way that if a provider doesn’t get credentialed for a particular insurance company, they are not able to receive payment from them. This can lead to potential revenue loss since providers don’t get paid for treating the patient.
Also when it comes to patients, the physician credentialing service protects their health and safety by only recommending qualified doctors for the job.

This whole procedure helps in maintaining a high standard of health and care in society as the ones who qualify – and are credentialed -are allowed to practice.

So if you are a healthcare worker looking to get credentialed, there’s good news for you. Practices that are credentialed by the insurance companies are considered authentic and legit. People can trust them and their services, which leads to an overall healthy mutual connection.

Medical Credentialing Steps

The Step-by-Step Roadmap For Credentialing Process

Since the process has a lot of moving parts, we have summarized them all into an easy and understandable process, making sure you get the steps required to get credentialed by an insurance company.

Step One: Preparation

The first part consists of your homework, and your research regarding which insurance companies would be ideal for you.

You can choose them from a variety of categories like which one is most popular, which one covers most patients, etc.

After your findings, next you have to do is gather all the necessary paperwork. These will be your documentation related to your degrees, certificates, certifications, medical licenses, etc.

Step Two: CAQH Registration

If you’re unfamiliar with CAQH, it is The Council Of Affordable Quality Healthcare (CAQH) which is the main data storage facility for providers’ credentials. They’re responsible for streamlining the verification process for insurance companies.

Since CAQH has such a big influence, it is important that you as a provider, maintain your CAQH profile with updated information. If you do that, your credentialing process will be relatively easy.

Also, if you practice in a specific state, consider your state’s licensing requirements for physicians as it can vary for different regions. This is as important as getting the board certification for physicians. Once you’re done with this process, you are good to go for the next step.

Step Three: Completing Applications

As mentioned in step one, once you have successfully gathered all your necessary documents, you need to start filling up the credentialing applications & forms that are provided by insurance companies or other credentialing organizations.

Make sure you fill in the form with the correct details and information to the best of your knowledge in order to avoid any problems/complications in the future.

Step Four: Verification

This is the step where you submit your documents and now it is the job of the credentialing organization to verify how authentic and genuine your documents are.

There are a few other steps involved in this process as well. This may include the verification committee running background checks on the information you provided, contacting references, and verifying educational, professional, and work history.

Step Five: Contracting

Once all the verification process is complete, and your provider’s qualifications successfully meet the requirements set by the insurance company – you, as a healthcare worker, are able to successfully enroll into a contract with the insurance company, finally making you an in-network provider.

Benefits of Medical Credentialing:

Not only credentialing is an important step, but it has certain perks as well. Here are some of the prominent ones that you should know regarding credentialing of your practice:
  1. Access to more patients:
    First of all, when you are a verified and credentialed healthcare worker, your patient pool automatically increases. This is how most of the patients who are covered by that particular insurance company, make their way to your practice. Even the patients prefer to choose practices that are credentialed by their insurance companies. Both lead to a win-win situation for you.
  2. Increased Revenue:
    Credentialing enables you to access the revenue directly from the insurance company. This means you are able to revenue a more stable and streamlined revenue stream that can also contribute to growing your practice.
  3. Streamlined Insurance Claims:
    When you’re in-network with the insurance company, the complex processes of claims and billing get smoother. Which leads to lesser payment processing burdens and more timely processing.
  4. Good Repute and Improved Trust Factor
    In the end, you get known for your professional and authentic way of working. This increases your reputation, spreads your good name, and inspires trust among you, your patients, and the insurance companies.

Choosing The Right Credentialing Service

Although the steps required for credentialing are more complex than they seem, we have tried our best to simplify them for you as much as possible. However, it’s better if you hire a reliable medical services company to do your credentialing. The best way to choose the right services is to look at their experience in the field.

And that’s why it’s recommended to use MaxRemind’s credentialing services to get credentialed by your favorite insurance company. With over 20 years of experience in the medical industry, we know all the ins and outs, all the necessary steps, and everything that is required for authentic and legit credentialing.

With extremely fast credentialing turnaround times, we aim to bring peace and focus to your practice. We want you to dedicate more time & energy to your patients and less to your practice’s administrative stuff. Feel free to contact us at (214) 736-3533 or visit MaxRemind Credentialing for more details.