What Is Credentialing and How it Works?
We understand that medical credentialing is an essential component of any functioning healthcare facility. Without proper provider credentialing, your facility’s healthcare professionals may be unable to perform certain tasks or treat patients at all. Most payor contracts include a requirement for credentialing.
There can appear to be an infinite number of steps in provider credentialing, with many moving parts. This quick guide will explain everything you need to know about credentialing in layman’s terms, from facility requirements to healthcare credentialing issues.
LIPs and credentialing
LIP is an abbreviation for licensed independent practitioners. A LIP is defined as an individual who, as permitted by law and regulation, as well as by the healthcare organization, provides care and services without direction or supervision within the scope of the individual’s license and consistent with the organization’s privileges.
How Does Credentialing Work?
When credentialing providers in your healthcare facility, you’ll most likely be looking for proof that they are legally classified as LIPs. Typically, this procedure necessitates extensive documentation.
Here are some of the most frequently requested details from providers:
- Name, birth date, gender, ethnicity, mailing address, and other personal information
- Social security number and other details about citizenship
- Immunization records and tuberculosis testing records
- Certificates for controlled substances (in certain states)
- A recently taken photograph
- A current curriculum vitae
- Medical school transcripts or other certificates of healthcare training
- Evidence of residency
- Specialties and licensing
- Number of National Provider Identifier (NPI), username, and password
- Certification by the Board
- Affiliations with hospitals and/or medical groups
- Sanctions or disciplinary measures
- History of malpractice claims
- Professional liability insurance documentation
- Documentation of continuing medical education
- References from peers
Your healthcare facility compiles all of this information about the medical practitioner and then verifies it with the appropriate licensing agencies, medical boards, and other organizations. The credential indicates that the provider has all of the necessary evidence of their ability to work in their assigned medical role.
Examples of credentials include:
- Letters of authority
- Badges
- Identification cards
- Certificates
Organization for Credential Verification
The medical credentialing process can be time-consuming and expensive for your facility. It typically takes 60 to 180 days or more to complete.
They make money by handling healthcare credentialing for you, allowing your facility to focus on day-to-day operations. CVOs can often meet your credentialing needs more completely, accurately, and quickly than an in-house team member juggling patient care.
Privileges
Your healthcare facility authorizes a provider to perform a limited and clearly defined set of patient care services based on your evaluation of that provider’s licensure and performance.
The privileges you grant are determined by the equipment, qualified staff, financial resources, and other factors at your healthcare facility. Only services that can be performed within your healthcare facility should be granted privileges. For example, you could hire a provider who is fully licensed to perform heart surgery, but if your facility does not have the capacity to support that privilege, you cannot include heart surgery as one of their authorized procedures.
Best Practices in Credentialing
If your healthcare facility handles credentialing in-house (rather than hiring a CVO), there are a few best practices to keep in mind.
Learn about your state laws – Not only do states have different requirements for credential renewals, but they also have different requirements for how quickly credentialing must be completed, what providers must do to be credentialed in multiple states, and how providers can transfer their credentials from one facility to another in the same state, and how providers must be credentialed to perform telemedicine services.
Learn about the CAQH – CAQH, or the Council for Affordable Quality Healthcare, is a non-profit organization that allows insurance companies to use a single, uniform credentialing application. Credentialing and credentialing will be much easier if you master the program’s requirements.
Make linkage a requirement in your contracts – Healthcare facilities are increasingly linking a provider’s start date to the submission of all credentialing paperwork. This encourages the provider to expedite the process, allowing them to see patients more quickly, which helps your practice grow.
Avoiding Common Credentialing Errors
Here are some of the most common mistakes to avoid:
Provider information that is no longer current – While much of the required documentation is not time-sensitive, some items are. You could be 60 days into the credentialing process when one piece of outdated information brings everything to a screeching halt. Healthcare facilities, for example, frequently report information on previous malpractice claims or disciplinary action slowly. Check that your information is up to date three times.
Primary source verifications are missing – It is common for providers to experience difficulties gaining access to their primary source certificates, records, licenses, and so on. They may turn to various secondary source verifications if they are under time constraints to complete their applications and submit all required materials. These sources frequently cause additional delays and may not be entirely accurate. Credentialing a provider with incomplete or incorrect verifications can cause problems for your facility.