A doctor speaks to a mother and her child.

Credentialing & Contracting for New Medical Service Providers

 The path to working and getting accepted into an insurance carrier’s network as a medical service provider involves a very thorough vetting process called credentialing. This is used by insurance carriers, facilities and hospitals to determine whether a medical provider meets all the necessary standards to participate in said network (Contracting).Nowadays, being in network is critical for many practices. Reason being, the rise in people being enrolled in health coverage means their provider needs to accept their insurance. If you aren’t credentialed—or, in a prospective patient’s network (Contracting)—they are very likely to go to a competing practice and save on potential out-of-pocket costs.

 How does the credentialing process work?

Before a physician can participate in particular networks, these requirements need to be passed:
  • Reviewing past education
  • Medical licensure
  • State and federal registrations and certifications
  • Professional liability coverage
  • Residency programs completed
  • References from colleagues and past professors
As you can imagine, this can be quite a time consuming procedure. If you are doing it yourself, the process can take between 3-4 months in order to submit all necessary paperwork and documentation, as well as following up and corresponding with insurance departments. Once credentialing is complete, it takes up to another 3 months to contract.

How can you make credentialing quicker?

  • Plan in advance. Remember, this process could take months. It’s important to start as early as possible. Some practices will start submitting credentialing information as soon as they have a hire date for their new physician.
  • Use your resources wisely. Some practices use in-house staff to manage credentialing. Given the scope of credentialing, it often falls beyond the capabilities of your typical medical staff. Thus, they’ll seek third parties to facilitate the process.There’s also the process of re-credentialing, for which you’d need employees who are constantly updating and monitoring the information to make the next go-around much smoother.

How to get started on your credentialing

A doctor speaks to a mother and her child.Fortunately, many software programs and services exist which can greatly expedite credentialing. They’re often provided at no cost and can save a great deal in terms of time and paperwork.Along with a state credentialing application, physicians will use CAQH ProView, a fast and secure way of submitting credentialing information. It’s also the most widely used credentialing database (we must note, do not leave any data entry boxes blank – this could lead to forms being rejected). Once you’re finished submitting your information, the insurance company will begin the credentialing process.If credentialing frustrates you, please know you aren’t alone. It’s a very time-consuming process. It is absolutely critical for the success of your practice, though, so please do your diligence and make sure you get fully credentialed & contracted.If you have any questions at all, please contact the staff at MBA Medical.

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Practice Management

  • Anesthesia Billing
  • Full-service medical billing
  • Patient account management
  • Encounter form design
  • Patient balance collections
  • Learn More

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