Understanding the Need for Physician Credentialing

Credentialing physicians is seen as essential to ensure proper billing and reimbursement.

As a healthcare provider or practice, you must ensure that your physicians are properly credentialed, and enrolled in the insurance payor plans you intend to accept – including those payors that are popular among your patient populations.

This needs to be determined well in advance of the physician’s start date.

What is credentialing?

Credentialing is the process of verifying that a healthcare provider meets the qualifications and requirements to practice in a particular setting, such as a hospital or a group practice. It is typically initiated by the healthcare facility applying to the payor, and involves verifying the provider’s education, training, licensure, and professional history.

It is common to start the credentialing process for a new doctor before they arrive, as long as you have all the necessary information and documentation. This can help to expedite the process and ensure that the new doctor is able to begin practicing (with the ability to request insurance reimbursement) as soon as possible after they arrive.

One common question that arises is: when can a new provider bill for their services?

Being credentialed with an insurance company allows the provider or practice to bill for services and be reimbursed. Unless the practice runs a self-pay clinic (common with purely cosmetic practices, when insurance willnotcover such procedures), insurance reimbursement is essential for the financial sustainability of the practice. (Please note that there are exceptions to the cosmetic rule, under rare conditions. For example, insurance will pay for cosmetic procedures such as breast reconstruction after breast cancer surgery.)

If a provider is not credentialed with the relevant insurance payor, the provider cannot bill the payor for services rendered. The provider’s options are to request that patients pay out of pocket, or write off the consult as a loss.

When should credentialing paperwork be initiated?

The credentialing and enrollment process can be complex and time-consuming, and it is not always clear how to navigate it effectively. It helps to keep a provider’s CAQH up to date. Depending on the payor, credentialing takes time. As a result of the pandemic, layoffs, and staffing shortages (on everyone’s end, including insurance), turnaround times are much longer.

The amount of time to get credentials can be as short as one month to a mind-boggling stretch that extends beyond a year. Assuming that the application has been fully filled out with all documentation attached, factors that influence an application’s processing time include whether the provider is simply adding a clinic or hospital location to an already-credentialed provider’s file, whether the payor is Medicare or Medicaid (a relatively fast turnaround), or whether it is a private carrier, which can easily run six to nine months, with some stretching the process well past a year.

So be prepared, and plan out provider onboarding based on credentialing expectations as soon as it is agreed they will be a member of your practice. Start the paperwork well before they officially start.

As for overworked office managers with staffing shortages, it is common to request assistance of service companies that can help with the credentialling process end-to-end, working with the provider to track down requested documents, licenses, and certificates, then following up with the payors. Service companies like TiaTech USA offer assistance in the credentialing process, allowing clinical and revenue cycle staff to focus on patient care and revenue cycle management.

How to start the credentialing process?

To start the credentialing process, the following information and documentation about the new-to-the-practice doctor is required:

1. Personal and professional information: the doctor’s name, date of birth, contact information, and their educational and professional background.
2. Licensure and certification: proof that the doctor is licensed to practice medicine “in the state where the patient resides.” While that may seem obvious for a traditional outpatient clinic, questions begin to arise when a longtime patient of the physician moves out of state, or if the physician wants to explore offering telemedicine beyond state lines. Physicians will also need to present any relevant specialty certifications, such as board certifications, controlled substances licenses, etc.
3. Professional liability insurance: proof that the doctor has such coverage. This is commonly referred to as medical malpractice insurance. Verify that the coverage and aggregate amounts meet standard minimums for the state in which the physician intends to practice, as requirements do vary by state. If the provider intends on conducting telemedicine consults, specifically request that the professional liability insurance carrier include telemedicine coverage on the Certificate of Insurance.
4. Education and training: you will need to provide transcripts and diplomas from the doctor’s medical school and residency program, as well as any other relevant training or education.
5. A Helpful Tip: if the provider has a FSMB FCVS profile, it will simplify document verification.
6. Clinical privileges: Payors will ask information about clinical privileges, including any restrictions or limitations the physician may have in this area.

Once you have gathered all of this information and documentation, you can submit it to the healthcare facility or payor for review and approval. The credentialing process can take several weeks or even months to complete, so it is important to start the process as early as possible.

How can you speed up a new provider’s Medicare enrollment transfer?

Here are a few steps you can take to accomplish this:

1. Gather all necessary documentation: make sure you have all of the necessary documentation, including the provider’s National Provider Identifier (NPI) number, proof of licensure and certification, and professional liability insurance information.
2. Submit the enrollment application as soon as possible: the sooner you submit the provider’s enrollment application, the faster the transfer process will be.
3. Check the status of the enrollment application online: you can check the status of the provider’s enrollment application online using the Provider Enrollment, Chain, and Ownership System (PECOS). This will help you to identify any issues or delays and take steps to address them.
4. Respond promptly to any requests for additional information: if the Medicare Administrative Contractor (MAC) or the Centers for Medicare & Medicaid Services (CMS) request additional information or documentation, respond promptly to avoid delays.
5. Contact the MAC or CMS if you have any issues: if you encounter any issues or delays during the enrollment transfer process, be sure to reach out to them directly.

It is important to note that the enrollment transfer process can take several weeks or even months to complete, depending on the complexity of the provider’s situation and the workload of the MAC or CMS. However, by taking the steps outlined above, you may be able to expedite the process and help the new provider to begin seeing Medicare patients as soon as possible.

Is it better for a new provider to bill under their personal NPI or the practice NPI?

It depends on the specific circumstances and the preferences of the provider and the practice. Below are a few factors to consider when deciding:

1. Type of provider: some providers, such as independent contractors, may prefer to bill under their own NPI in order to maintain their independence and autonomy. Other providers may prefer to bill under the practice’s NPI in order to simplify billing, to take advantage of the practice’s negotiated reimbursement rates, or to participate in the practice’s additional benefits and resources.
2. Type of service: some services may be more suitable for billing under the provider’s personal NPI, while others may be more suitable for billing under the practice’s NPI. For example, a provider who is offering a specialized service or who is building a reputation in a particular area of expertise may benefit from billing under their own NPI.
3. Billing and coding: billing under the practice’s NPI may simply be easier, as it allows the provider to use the practice’s existing billing and coding infrastructure, which is often streamlined and highly cost-efficient.

The benefit is often significant when a comprehensive revenue cycle management tool is used by the practice, such as TiaStat’s state-of-the-art AI-assisted platform, with the ability to track notes, predict coding, and display the cycle in billing, collections, and outstanding revenue.

However, when such tools aren’t being made available to the provider, billing under the provider’s personal NPI may be necessary in order to accurately reflect the provider’s role and responsibilities in the service.

Ultimately, the decision of whether to bill under the personal NPI or the practice’s NPI will depend on the specific circumstances and the preferences of the provider and the practice. It may be helpful to discuss the options with colleagues, an accountant, or a healthcare attorney to determine the best approach.

What is PECOS and CAQH? When and how must doctors re-attest to these databases?

PECOS is a database maintained by CMS that contains information about healthcare providers who are enrolled in the Medicare program. Providers must use PECOS to enroll in Medicare, change their enrollment information, or to opt out of the program.

The Council for Affordable Quality Healthcare (CAQH) is a nonprofit organization that maintains a database of information about healthcare providers. Many payors and healthcare facilities use the CAQH database to verify provider information and to streamline the credentialing and enrollment process.

Doctors must re-attest with PECOS and CAQH when their enrollment or credentialing information changes. This could include changes to their personal or professional information, licensure or certification status, or clinical privileges.

To re-attest with PECOS, doctors must log in to their PECOS account and update their information as needed. To re-attest with CAQH, doctors must log in to their CAQH account and update their information as needed.

Both PECOS and CAQH have online guides and support resources to help doctors with the re-attestation process.

When can a new provider bill under another physician’s name in a practice?

A new provider may be able to bill under another physician’s name in the practice under certain circumstances. However, there are strict rules and regulations governing when and how this can be done, and it is important to ensure that you are complying with all relevant laws and regulations. It is important to note that the rules and regulations governing billing under another physician’s name vary by state and by payor. It is essential to carefully review all relevant laws, regulations, and payor policies to ensure that you are complying with all requirements. You will need expert guidance from a revenue cycle management expert and a healthcare attorney to navigate this.

When is filing for temporary hospital privileges worth your time?

Filing for temporary hospital privileges may be worth your time if you are a healthcare provider who needs to see patients at a hospital on a temporary basis, such as while you are filling in for another provider or while you are in the process of obtaining full privileges. Temporary hospital privileges can allow you to see patients at the hospital, use the hospital’s facilities and resources, and bill for the services you provide.

There are a few factors to consider when deciding whether to file for temporary hospital privileges:

1. Time and effort: filing for temporary hospital privileges can be a time-consuming process, as it typically involves completing an application, providing documentation, and undergoing a review and evaluation process. You should consider whether the time and effort required to file for temporary privileges is justified by the expected benefit.
2. Need for hospital privileges: you should also consider whether you have a need for hospital privileges. If you do not anticipate seeing patients at the hospital on a regular basis, or if you are able to provide the necessary services without hospital privileges, it may not be worth the time and effort to file for temporary privileges.
3. Duration of need: you should also consider the duration of your need for hospital privileges. If you only need to see patients at the hospital for a short period of time, temporary privileges may be a more practical option than seeking full privileges.

Ultimately, the decision of whether to file for temporary hospital privileges will depend on your specific circumstances and needs. It may be helpful to discuss the options with colleagues, an administrator, or a healthcare attorney to determine the best approach.

Is there a way to keep track of your collections?

Credentialing in of itself doesn’t ensure reimbursement. There’s another revenue-collecting factor to address.

Today, more and more physicians are covering clinics and hospitals at multiple locations. Even if the new physician or existing physicians in the clinic are credentialed, keeping track of patient encounters for each provider can become so overwhelming that the simple fact they’re credentialed almost becomes moot if claims aren’t or can’t be submitted.

Looking at the potential volume of an average provider’s patient schedule: one provider seeing 15 patients a day, 20 days a month quickly adds up to 300 patients a month.

Over 12 months, that number jumps to 3,600 patients a year, per provider, in the practice. Five providers in that practice brings the client encounter figure up to 18,000 encounters to track. With encounters multiplying even faster with each new provider added, and often only one office manager or administrator to coordinate the daily patient census and claims, the task becomes daunting. Regardless of best efforts, money earned is lost despite all the work undertaken to get physicians credentialed.

Most commonly, paper billing and Excel charts are used by managers or administrators. Unfortunately, Excel is a spreadsheet, not an RCM tool to ease the workload of each stakeholder in the RCM process.

The doctor wants to know their productivity: whether or not they are carrying their weight within the practice. The administrator is trying to assist in completing the process. The coder is waiting for notes to be signed, and billers are hoping all the information on insurance and demographics is complete for a streamlined submission.

But often, this is not the case. Simple but critical aspects of the process get dropped by even the most diligent and experienced staff, because the volume of claims grows quickly. Each stakeholder is uncertain about where the holdup is located (or, worse, even whether a holdup exists.) The reality is, the holdup can be trapped on the Excel sheet of one individual who is too busy to help complete the process, is off on sick leave, has left the practice, or is away on vacation. The process is complex, and hard to track. Very few people have the capacity to verify at those volumes that the insurance was applied successfully, the eligibility is complete, the clinical notes were finalized, the physician has attested, the encounter was coded and sent to the billing team, and how to correct a denial or rejection by the payor. It’s almost impossible to stay above water, as with each new day, new claims keep rolling in.

It is often said, as a rule of thumb, that each encounter averages $100. So, if just 10 percent of encounters aren’t billable, per provider, per week, a practice of five could conservatively lose $180,000 per year, and often not even know it, based on the complexity and demands of the process. Billers are overwhelmed with encounters and simply can’t stop to chase encounters that are incomplete, especially if they are not being well-tracked. The faulty encounter falls through the cracks. Documentation tracking and optimization platforms like TiaTech improve document completion and optimize coding, diminishing the time spent by clinicians in documenting and allowing clinical staff to spend time assisting with patient care.

Insurance companies benefit if the practice forgets, overlooks, or is unable to submit the claim. Advanced RCM platforms with artificial intelligence, like TiaTech’s TiaStat platform, assist the practice, coder, and biller in winning the battle of billing, to capture dollars that would otherwise be left behind.

In Summary:

The credentialing and enrollment process can be complex and time-consuming, but it is essential to ensure that your providers are properly credentialed and enrolled in the payor plans you accept. By understanding the process and taking the appropriate steps, you can ensure that your providers are able to bill for their services and provide high-quality care to their patients. In addition, considering the issue of temporary hospital privileges can be helpful if you have a need for hospital privileges on a temporary basis, but it also requires a commitment to follow through on the supporting documentation.

By following the steps outlined above and seeking guidance as needed, you can navigate the credentialing and enrollment process smoothly and efficiently.

Programming note: Listen to Susan A. Vestevich today on Talk Ten Tuesdays, 10 a.m. EST.