Health care providers who wish to practice and get hooked in to the network of insurance carriers have to undergo a thorough vetting process, namely, provider credentialing. Enabling health care facilities, insurance carriers, and hospitals to determine whether the provider is qualified and meets the essential standards required to be a part of the network, this process proves crucial in the medical industry.
Significance of Provider Credentialing
Examining, reviewing, and authenticating the certifications, licenses, and work experience of a professional and ensuring that they are all in order is essential in medical industry. Confirming that occupational and other related criteria are met is vital in today’s litigious society. With rise in medical-legal litigation, and health care facilities becoming targets of lawsuits, complete verification of the professional credentialing of providers is imperative.
Serving the double purpose of protecting health care organizations from potential legal tangles and ensuring the capability of practitioners to provide quality health care services, the process of provider credentialing proves to be of immense value to new health care providers.
Criteria Authenticated by Credentialing Verification Organizations
- Provider’s education
- Training and internships
- Certification and licensure in the specialty
- Registration to practice in a specific field of medicine
- Existing certifications and upgrades needed in future
- Experience and skill in the respective field of practice
The Credentialing Process
New health care providers, before they may participate in insurance networks, need to get certain factors verified and confirmed. This process normally takes between 3 and 4 months to complete. After the verification process is over, it takes further 3 months for contracting – becoming a part of the insurance network. With prudent planning and optimal resource usage, providers can expedite the credentialing process. There are software applications and services that help in getting this otherwise tedious process performed quickly.
Determining the credentials of a new provider involves contacting the primary sources such as the particular medical school that has granted the degree or degrees and the organizations (professional and governmental) that have conferred the license or certificate. In addition to this, the candidate’s related employment and practice history are also verified.
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