Physician Credentialing Affects Bottom Line of a Practice

Karrie Plaskett, left, of Management Resource Group consults with a colleague.

Physician credentialing is a detailed process that reviews physician qualifications and career history that includes education, training, residency, and licenses. It is an important process because it affects the cash flow of a practice.

Physicians, as well as physician assistants, nurse practitioners, nurse anesthetists, psychologists and social service providers must be credentialed with all of the various payers before a practitioner can see patients.

"A provider must be credentialed with each insurance payer," says April Trammell, patient account representative for Advanced Surgeons in Birmingham. "Each payer has its own procedures for credentialing, so it is a meticulous process to provide the necessary information to each one. Once I have a physician's curriculum vitae and license information, I contact each payer to find out what else they need."

"Providers must have all documents in order and have registered with an Identity and Access (I&A) management site which acts as a hub for a provider's individual information and allows that provider to connect with the various groups where he or she will be seeing patients," says Karrie Plaskett, director of business development for Management Resource Group, which assists individual and group medical practices with provider credentialing. "We make sure that the application is completed according to carrier specifications, and we monitor the application until the letter of acceptance is received. We track provider records, alert the physician when updates are needed and inform them when approval letters are received and effective dates are issued."

A new provider with a newly obtained license must register for a National Provider Identifier (NPI), a unique 10-digit identification number issued to health care providers by the Centers for Medicare and Medicaid Services (CMS), and establish the individual provider numbers.

"Before contracting with any of the Medicaid or Medicare CMOs, a provider must have active Medicare and Medicaid provider numbers," Plaskett says. "Because insurers are required to follow state and federal CMS guidelines, they will not credential the provider unless the provider has already been credentialed by traditional Medicare and Medicaid. All of the reporting they do is tied to the unique Medicare and Medicaid provider numbers."

The National Practitioner Data Bank is also part of the process, and providers can use its website to run a self-query. "We recommend that a provider run a query before submitting applications so they can address any issues prior to beginning the credentialing process," Plaskett says.

About 85 percent of commercial payers use the Council for Affordable Quality Healthcare (CAQH) to maintain credentialing information. It is important that the providers maintain files with copies of all applicable documents and keep them up to date. "Make sure the NPI registration is up to date and accurate. Not only is it used by insurance carriers, but providers use it to get NPI numbers and fax numbers on the referring providers," Plaskett says. "We had a client whose Care Improvement Plus claims began to be denied, and we determined there was a discrepancy between what was on the claim and what was in the NPI Registry. It turned out that the NPI registry had not been updated in years. It pays to keep it correct."

Trammell also emphasizes the importance of keeping all information and the CAQH identification up to date. "Payers check this information, so keep everything current and make sure the person doing the credentialing gets the updated information," she says. "I keep a spreadsheet to keep up with the information, reference numbers, and each payer's contact. It makes it easier to follow up on each provider's credentials."

Plaskett says they often are asked if providers can begin seeing patients during the credentialing process. "We tell them they are risking loss of revenue if they see patients before they are effective, because they never know what the effective date will be," she says. "Generally, they can submit claims with commercial payers, but they would be processed as out-of-network and the patients would be responsible for higher deductibles and coinsurance amounts."

Claims for Medicare, Medicaid and BlueCross BlueShield should be held until the provider has an effective date. "Medicaid says they credential providers in 14 days, but that is if they have all the documentation they need," Plaskett says. "Bottom line, there is still no guarantee so it is best to start the credentialing process as soon as possible so all approvals are in before the provider starts seeing patients."

Photo 1

Karrie Plaskett, left, of Management Resource Group consults with a colleague.

Photo 2

April Trammell, right, discusses credentialing information with a client.


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Physician credentialing; medical credentialing; National Provider Identifier; Na


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