Physician credentialing is the process of verifying the credentials of a physician or a provider. The term is used interchangeably to describe provider enrollment. Healthcare credentialing is verifying factors such as training, education, and proven skills of health care practitioners.
Basic Steps in the Credentialing Process
Fundamental steps taken during credentialing process involve identifying medical institutes, verifying licenses, verifying different training such as residency, internship, fellowships, and others. Reaching out to the entity providing the education, this verification is performed on the primary source. Information accuracy as given by providers is also verified.
Verification of medical licenses involves contacting the licensing authority to check whether the license is active and without any restrictions. Similarly, verification of education includes checking at the medical university whether a degree has been awarded. Depending on the particular factors that need to be verified, this process can be lengthy.
Health care facilities utilize credentialing process as part of their verification strategy that allows practitioners to participate in care provision in the campus. Proper provider credentialing helps ensure the quality of the practice. Without credentialing, insurance carriers may delay or refuse payments, even if the physician provides competent and essential medical services.
Provider Enrollment Process
This is the process that requests participation in a medical insurance network as active provider. This process involves requesting enrollment with a plan, completing credentialing plans and enrollment application, submission of copies of insurance and licenses, and signing contracts. Commercial carriers make us of Council for Affordable Quality Health care (CAQH) for obtaining credentialing information. In the process of enrollment, providers are expected to have a comprehensive and updated profile in the CAQH system.
Time taken for the provider enrollment process depends on the speed at which documentation and follow up are performed. Service companies help health care providers in the enrollment process by charging a fee.
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