The credentialing and re-credentialing processes are significant elements of your health plan quality management program. The credentialing and re-credentialing processes serve to ensure that qualified professionals in your health plan provider network are capable of meeting the needs of those seeking and receiving services.
Credentialing and re-credentialing is an ongoing evaluation process that ensures practitioners’ current competency by confirming individual practitioners’ training and ability in specific specialty areas. This level of review is designed to ensure that individual practitioners have demonstrated the necessary training, experience, qualifications, and ongoing competence for the services they deliver.
The rules for credentialing and re-credentialing vary based on the type of provider. Before providing services to members, physicians, nurse practitioners, physician assistants, psychologists, and all other health professionals registered to bill independently or provided services, they are licensed to offer and must be credentialed.
Suppose your health plan delegated any credentialing and re-credentialing or provider selection responsibilities. In that case, a health plan must retain the right to approve, suspend, or terminate any chosen providers and revoke the delegated function if the charged process is not performing satisfactorily.
The Application Process
Accomplishing in-network status starts with an application. When applying, make sure you use the most recent version or copy of the insurance carrier’s application form. Using an out-of-date version can cause application delays, if not outright rejection. Also, make sure that all of the sections are filled out.
Why Credentialing/ Re-credentialing is Important?
Many people, including those in the medical billing services industry, are unaware of the significance of credentialing. As a result, industry leaders have fought for the authority to improve competency standards for healthcare professionals by requiring provider disclosure and accurate recordkeeping.
The idea is to ensure that the qualifications of each provider in your business or clinic are transparent. Providers have been charged with duties above their qualifications and experience due to simple human faults. Physicians with an expired license may still practice in specific circumstances. In the end, this can be a nuisance for professional clinics that employ a variety of medical providers and a risk to patient safety.
Many office and clinic owners are now more conscious of the necessity of rapid and accurate credentialing and re-credentialing services. As a result, they have recruited experienced healthcare consultants to handle crucial elements of business, such as medical billing and other services.
Performing proper credentialing of new clinicians brought into the practice is not only mandated by payers, but it is also critical to the clinic’s success and reputation. When everyone on staff has been credentialed and a thorough attempt is made to conduct re-credentialing services as needed throughout time, risk and cost are decreased.
Outsourcing Credentialing and Re-credentialing Services
Our healthcare consultants may assist with rapid and accurate credentialing or re-credentialing services as needed, in addition to all of the medical billing services, training, and support available at Info Hub.
Outsourcing these services can help your in-house medical billing department reduce effort and speed up the certification process for new and existing providers. In addition, by centralizing data for each provider to meet compliance requirements for insurance payers and Medicare systems, this solution helps to decrease fraud and waste.
- All licensed individual health care practitioners must be credentialed to participate in the Info Hub networks and see Info Hub members.
- Info Hub adheres to industry standards for credentialing and re-credentialing of healthcare workers.
- The National Committee on Quality Assurance (NCQA) and the Centers for Medicare & Medicaid Services (CMS) set credentialing standards (CMS).
- The Council for Affordable Quality Healthcare (CAQH) and other state-specific institutions created a contract with services like Info Hub to collect credentialing and re-credentialing application data and Aperture CVO to validate required components of the credentialing application and process.
Healthcare organizations and providers must obtain credentialing from as many payers as possible so that patients can continue to utilize their plans in the future. Credentialing and re-credentialing ensure that a physician or healthcare organization satisfies the payer’s requirements.
So, send your credentialing and re-credentialing documents to Info Hub, and we’ll handle the rest.