Tips For Credentialing

Know Your Payer Information

You'll want to know what your payers require and will accept. This is a good place to start:

• Know the time it takes for your payer to get credentialed.

• Know how much it costs to be paid by them and whether they charge extra when using electronic funds transfers (EFTs).

It's also important that you understand the requirements of other providers that you work with, such as hospitals or clinics.

Avoid Getting Denied The First Time.

The credentialing process can be long and complicated, so it’s important to avoid getting denied the first time around. Make sure you have all the necessary documents, credentials, and information before you submit your application for credentials. Your chances of being accepted are much higher if you do this step right!

• The payer (the insurance company) will want proof that you are licensed with a valid license in good standing from approved licensing authorities. They will also review your records to make sure that you have completed at least two years of graduate-level education as well as one year of supervised experience in clinical practice.*

Develop A Relationship With Your Payers

You should be developing a relationship with your payers. 

They are the gatekeepers for credentialing and often have to make the decision about whether or not to credential providers.

This can be done by:

• Calling your payer and asking them how they want you to reach out to them (phone call, email, etc.).

• Not being afraid of rejection and continuing our efforts until we get through.

• Asking other providers that you know who have been credentialed by them if they could give you some tips on how they were able to do so successfully.

Make sure you’re up to date on the most recent rules and regulations

As a medical credentials professional, you may be wondering how to keep up with the latest changes in the industry. If so, there are a few things you can do that will help you stay current on all that's happening with credentialing.

• Read relevant trade magazines and newsletters. These will give you an overview of what is going on in your field, as well as tips and advice from industry leaders on how to improve your work practices.

• Check out online journals specific to your profession. Journals like The Journal of Health Care Compliance News provide updates on regulatory trends affecting credentialing professionals as well as articles about new technologies and best practices for managing compliance issues at hospitals or other healthcare facilities.* Sign up for social media accounts related to your field; this includes Twitter feeds, Facebook groups (such as those hosted by NCQA), LinkedIn groups (like this one!), etc.* Attend local conferences put together by other organizations within the healthcare space—this will give them an opportunity to share their knowledge base with others without having outside speakers come into town every month!

Track your credentialing status closely and always know where you are in the process

• Track your credentialing status closely and always know where you are in the process.

• Know the payer's process, including your expected date of completion, what happens if it takes longer than expected, and any other policies or procedures that may affect you or your patient.

• Know your own rules, regulations, and policies regarding credentialing and make sure they are followed consistently by all staff members who may be involved with this process (e.g., the billing department). Make sure that all staff members understand how to deal with questions from consumers about their credentials that come into their office; if an employee is unsure about how to respond then send them back to their supervisor for help instead of making up an answer on their own

In a highly competitive environment, even small problems can bring big trouble, so it is important that you keep these tips in mind when working on your medical credentialing.

• Make sure you know your payer information.

• Avoid getting denied the first time. Develop a relationship with your payers early on, and keep it going over time by staying current on how they do business.

• Be aware of all rules and regulations for each type of insurance product in which you participate, including those that are part of ACA compliance requirements as well as state mandates like OON rules or other related issues such as network adequacy laws (for example, some states require minimum numbers of providers within a specified distance from designated zip codes).

• Track your credentialing status closely and always know where you are in the process -- understanding how credentialing works can make a significant positive difference in how smoothly a practice runs and the pace of cash flow. Problems with credentialing can be expensive and drain productivity, so it's important to have a process in place and a plan for ensuring credentialing always remains up to date.

Conclusion

The process of credentialing is a time-consuming and complex one. But with the right approach, it can be quite rewarding to see your organization help more people than ever before.

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