In healthcare, medical credentialing is like the background check for your favorite superheroes – it ensures they have the qualifications and skills they claim to possess. But just like superheroes, even healthcare providers need a little help occasionally to streamline the credentialing process. 

The process of medical credentialing is no walk in the park. Ensuring that healthcare providers meet stringent compliance standards is necessary for medical operations. Unfortunately, it’s not uncommon for applications from healthcare providers to be denied due to missing information or inaccuracies.

Whether you’re running a medical practice, have just started a practice, own a clinic, or are a hospital administrator, making the credentialing process easy and efficient helps your practice stay on track and adhere to compliance. In this blog, we’ll explore the challenges of credentialing and how to streamline this process.

Why Streamline Credentialing at Your Practice 

Quick reasons: 

  • Adhere to compliance 
  • Follow all state and federal policies 
  • Builds trust in your providers
  • Save time and money 
  • Avoid legal ramifications 

Errors can crop up in any procedure, but the stakes are high regarding healthcare credentialing. For instance, a hiccup in certifying nursing staff can jeopardize a nurse’s job security. Moreover, credentialing blunders have the potential to tarnish the hard-earned reputation of a healthcare institution. In simple terms, no one can afford the financial and legal ramifications resulting from a poorly managed healthcare credentialing process.

Take a look at the documents needed for processing credentials for a new provider:

Credentialing Documents Needed for New Providers

  • Personal information like email address, street address, phone, etc.
  • Driver’s license
  • Social Security card
  • A recent photograph signed and dated in the margin
  • Medicaid number
  • Medicare number
  • Copy of National Provider Identifier (NPI#) documentation and confirmation letter
  • UPON number
  • Federal Tax ID number
  • Permanent Resident Card, Green Card, or visa status for non-US citizens
  • Copy of all current active state license wallet card(s) and wall certificate with expiration date and number
  • Copy of current Federal DEA and current State Controlled Substance Registrations or certificate(s)
  • Copy of medical school diploma and training certificate(s), internship, residency and fellowship certificates
  • Copy of current Board Certificate, including the name of the issuing board and dates of board certification/recertification
  • Documentation of hospital privileges
  • Completed Delineation of Privileges Form
  • Surgical logs
  • Completed Locum Tenens Practice Experience Form (if applicable)
  • Work history, including all practice locations and employment affiliations

  • Malpractice claims history with details

  • Third-party documentation (i.e., court documents, dismissals) for all malpractice/disciplinary actions OR completion of appropriate explanation form (if applicable).

  • 10-year insurance claims report
  • Current Curriculum Vitae with complete professional history in chronological order and no gaps (month and year must be included)
  • Three written letters of recommendation from providers who have directly observed the candidate in practice within the past year, assessing clinical competence and specifying dates observed
  • Certificate of Professional Liability Insurance Coverage or declaration page (face sheet) of policy (if applicable)
  • Case logs from the last 24 months (if applicable)
  • ACLS/BLS certification
  • DEA certificate
  • Mammo #s and MQSA (if applicable).
  • Current CME (CME activity for the past three years)
  • Residency diploma
  • Military discharge record -Form DD-214 (if applicable).
  • Copies of current immunization records and most recent TB test results (if available)
  • Copy of NBME, FLEX, USMLE, or SPEX scores
  • Copy of Any BLS, ACLS, ATLS, PALS, APLS, or NRP certificate(s)
  • If a foreign graduate, ECFMG certificate number and info on Fifth Pathway

Credentialing takes time and money away from your practice, especially if you delay too long or receive denials. According to the National Committee for Quality Assurance (NCQA), the average credentialing process for a healthcare provider can take between 90 to 120 days, with some cases even taking up to 180 days or more. This timeline varies based on the provider’s background’s complexity and the credentialing process’s efficiency within the healthcare facility. (Source: NCQA)

In addition, credential-related denials cause significant issues, according to the Medical Group Management Association (MGMA). The most common reasons for credentialing denials include missing or incomplete application information, malpractice history issues, and licensing and education verification problems.

1. Keeping Up-to-Date with Information 

Imagine your practice as the Avengers, and you must assemble your heroes quickly to save the day. To do this efficiently, you need a command center. Similarly, having a centralized credentialing system is like having your superhero command center. 

One of the best things you can do to streamline and maintain this process is through a centralized credentialing system. Many even come with reminders and scheduling. 

Here are two things you can set up to make this easier: 

  • Digital Credentialing Software: Consider this your Jarvis (or any favorite AI companion). It’s there to organize, track, and ensure all your heroes’ credentials are current. No more digging through mountains of paperwork!
  • Online Provider Portals: This is your superhero hotline, like the Bat-Signal, but online. Providers can quickly update their credentials, making the process seamless and efficient.

2. Start Credentialing Early

The healthcare credentialing process is a time-consuming affair. The evaluation of an application alone can extend up to 90 days. The process might stretch to six months if additional stakeholders are in the mix, such as contract negotiators and health insurers. Such a protracted duration can significantly disrupt the normal operations of most healthcare organizations. 

  • Regularly Review and Update Provider Data  – Your healthcare providers should be proactive in keeping their credentials current. Regular reviews are your “Spider-sense” for staying compliant. 

3. Avoid Compliance Problems 

Are you currently compliant? How much of your time do you spend credentialing vs. worrying about credentialing? The biggest issue is that you could be out of compliance if you don’t update credentials regularly. Healthcare credentialing policies, regulations, & standards differ from one state to another. These rules & guidelines are unpredictable and constantly change. 

It is best to use a trustworthy credentialing service provider or system to follow up with diverse and changing rules.

  • Outsource Your Credentialing Process: Hiring a professional credentialing service is like calling in the Justice League to save the day. They’re experts in the field and can handle the complex work, leaving you free to focus on other critical aspects of your practice.  

Outsourcing saves time and money, but it also means a professional always watches your back for compliance. These experts are well-versed in the intricacies of credentialing, including understanding the constantly changing regulations and requirements set forth by insurance companies and government agencies.

4. Certified Telehealth Providers 

Are providers offering telemedicine services without certification? Telemedicine is like the DeLorean from Back to the Future – it takes healthcare providers to different time zones (virtually). Streamline your time-traveling heroes by ensuring they’re all credentialed for online care; otherwise, your practice could face issues for any provider not credentialed for telehealth service. 

5. Pay Attention to State Regulations  

Conducting thorough research into the regulations, laws, and guidelines pertinent to your healthcare system is paramount. Given the variations in standards from state to state, seeking the guidance of healthcare credentialing experts who possess in-depth knowledge of these rules is crucial for ensuring a seamless transition to compliance.

We strongly recommend reviewing your state’s regulations for:

  • Licensing requirements 
  • Certification criteria
  • Educational qualifications

Start Streamlining Your Credentialing Process 

Credentialing in healthcare might sound like serious business, but it can be a breeze with the right tools and a touch of humor. Whether you’re building your Avengers-like command center, keeping your credentials up to date, or calling in the experts to assist, the goal is to streamline the process while maintaining compliance.

We hope these five tips help with credentialing at your practice. If you want to entrust your credentialing to a professional service, try our medical credentialing service. We’ve been streamlining this process for medical procedures for over 20 years. 

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