Credentialing: The Link Between Your Practice and Its Revenue

The importance of proper credentialing cannot be understated. To ensure a steady cash flow in practices, it is important to respond timely to credentialing requests by insurance carriers as well as being prepared with all the proper documentation. A Credentialing request could be as simple as providing copies of your Malpractice certificate or Medical Licenses to carriers all the way to full re-credentialing with a carrier or state agency. Failure to respond to these requests could result in deactivation and loss of finances. After being deactivated from a carrier, a provider could be required to re-enroll in the program and claims could be holding anywhere from 90-180 days depending on the carriers processing time. Commercial carriers such as Blue Cross could require re-credentialing every 2-3 years. Medicare requires revalidation every 5 years, while Medicaid could require annual credentialing in your state.

Be prepared when hiring on new physicians or starting with a new practice to supply information as early as possible to credentialing staff as some carriers do not allow backdating (i.e. Florida Medicaid, Florida Blue Cross, Medical Degrees, Board Certificates, IRS Documents, Social Security Cards, Current C.V.’s).  Certification for individuals or practices and practice ownership breakdown are some of the items that will be needed during the credentialing process. CMS and the Affordable Care Act have caused carriers to become stricter in these requests in an effort to prevent fraud in the medical industry. Blue Cross, Medicare and Medicare Credentialing for new providers could take 60-120 days. California Medicaid can at times take 180 days for credentialing. All this while, claims will be holding. Prior notification to commercial carriers is important for determining the effective date with that carrier. For example, Indiana Blue Cross requires a 30 day notice before the providers start date. If they are notified after the provider starts, claims will process out of network for the next 30 days.

An online credentialing database becoming more predominant in commercial credentialing is CAQH. CAQH is the Council for Affordable Quality Healthcare. All of your practice information, documentation, medical education and background can be stored on this database making the credentialing process more streamlined and avoid requests by multiple carriers.
           
When making changes in the organizational structure of a practice, such as the payment address, legal or Doing Business as Name, service address or changes in TIN, require notification to carriers. New TIN’s could require a new enrollment. Remember proper planning and notification can help avoid the pitfalls of financial dips.  If you have other credentialing related questions, please contact your Account Manager.