Medical credentialing is not only a critical component of developing a practice that delivers the highest level of patient care, but it’s also essential for insurance reimbursement. Through the credentialing process, states and insurance providers determine which medical providers meet their requirements. Doctor credentialing reviews a host of different pieces of information for each medical professional, including:
- Education and training
- Residency
- Licensing
- Specialty certificates
- Qualifications
- Work history
A medical professional must complete this review when they start at a new practice or change states. Medical credentialing consists of a few different processes: provider credentialing, provider enrollment, and privileging.
- Provider Credentialing: The process of verifying skills, training, licensing, qualifications, etc.
- Provider Enrollment: The process of enrolling a provider with insurance plans.
- Privileging: Approving providers to perform specific procedures and granting them a specific set of privileges (usually not required for Optometrists).
Things to Know About Your Credentialing Timeline
Credentialing can take anywhere from 90 to 150 days, depending on the time of the year. Most commonly, it will take 45-60 days to gather and complete provider data and another 90 days for the approval of the documents from the insurance carriers. Ensuring that your application paperwork is completed accurately and without missing information is the best way to avoid delays and increased admin time of getting credentialed.
Staying current with relevant organizations, like the Coalition for Affordable Quality Healthcare (CAQH), can help make your credentialing process a more simple. Don’t forget your CAQH attestations — the paperwork that ensures your forms are accurate and valid. If you must change any information after the application has been completed, you’ll have to rewrite and resubmit your attestation. Remember:
- Each state has specific credentialing laws and regulations, so make sure you’re aware of any particular rules that could apply to your situation.
- With some commercial payers contracting is done separately from credentialing.
Post Credentialing
Once a provider is credentialed with an insurance company, they enter into a contract with the insurance company. This contract allows them to bill and be reimbursed as an in-network provider with that insurance company.
Re-Credentialing
Recredentialing, also known as re-enrollment and revalidation occurs periodically and requires a provider to repeat the credentialing process. Providers will receive a letter letting them know that they are up for re-credentialing. If they don’t complete this within the deadline, their credentialing status is suspended or until the process is completed and approved.
How OMS can Help with Your Credentialing
The process of credentialing can be an administrative time burden for many practices. OMS can help take this hassle off your practice and handle the credentialing process for you.