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What is the credentialing process for healthcare providers?

Feb 11

Like never before previously, we consider medical healthcare providers to be saints because some of them take a chance with their lives to treat and save our loved ones, friends, and family. Undoubtedly, even before the COVID-19 wave, specialists and medical attendants, nurses are among the highest-ranking professions. Patients have faith in the systems of check and balance of governing rules that empower suppliers, doctors, and nonphysicians to perform medical care procedures and overlook the authorities.

Medical providers who want to work with the medical health organizations or associate with medical care frameworks and hospitals go through a mind-boggling process known as Provider Credentialing. You can outsource medical credentialing services for better results for your healthcare organization, and it is the best way to stress-free the healthcare providers. 

What is Provider credentialing?

When we think of the doctor-patient relationship, we take this relationship as one. Still, due to administrative functions in the healthcare organization, They have the patient's responsibility to provide them high-quality care. Provider credentialing is the process of verifying the records of the healthcare providers according to their background, education, history, experience, and competency level. It is also the process in which the organization allows the medical privileges to the candidates based on their competence, performance, experience, diagnosis, and treatment of the patient. They also judge the candidate with the prescribed medication in a hospital setting from the history. 

Provider credentialing is a complex process in the medical care associations and hospitals used to assemble and check professionals' capabilities to practice the medicine. It is performed on specialists utilized by the association and those assistants, and Credentialing is not commonly practiced on specialists in private medical practices. Moreover, in healthcare, medical transcription is also the process that generates and edits the dictated reports of the doctor, physician notes, procedures, diagnosis electronically to represent the patient treatment history and streamline the patient transcription files. By outsourcing from medical transcription billing corporation you will save your medical staff's time and effort to focus on patient care.

Private and Government insurance companies also conduct the Provider credentialing with the help of Credentialing Verification Organization (CVO) or independently (with the help of hospitals or healthcare firms). 

How does Provider credentialing work?

The provider credentialing process is finalized in several stages by a provider's association's or payer's credentialing office, third-party Credentialing Verification Organization (CVO). 

Provider credentialing staff does the following steps:

  • The initial step is to collect information from different resources, and it also includes the Provider's efforts and follow-ups. 
  • The documentation and data collection can be done through Primary source verification (PSV).
  • Provider credentialing identifies and accesses any sort of discrepancies, problems, etc.
  • Provider credentialing also suggests whether the payer will consider clinical privileges or be enrolled with the payers. 

 Primary source verification (PSV)

The primary source of gathering information is the authentic source which means the issuer of the documents and data. The secondary source of information is probably biased, unreliable, and inaccurate. In this modern era of technology, technology can easily fabricate and exaggerate healthcare providers' degrees and qualifications. So, Primary Source Verification is essential for the verification of the healthcare providers, and it is also the crucial stage of credentialing. If the results are not good and patients die due to the negligence of the healthcare providers, lawsuits can sue and take serious action against the fake healthcare providers. There are specific steps which are as follows includes: 

  • Verify the Provider's degree, identification, criminal record, OIG status, and background status issued by the Government.
  • Recheck the application before submission 
  • Verify the Provider's background history, education, address, experience, fellowship, schooling, and training programs. 
  • Verify the Provider's all kinds of certifications, including the board certification. 
  • Verification of the DEA Registration Number other registrations and verify the state license. 
  • Verification of the bank details (National Practitioner Data Bank Query)
  • Verify the professional claims history, work history, and liability coverage. 
  • Verify the references, including the panel, department chair, program director, etc.).
  • Verify the primary source verification (PSV) requirements of the State. 
  • Verify the URAC, NCQA, TJC required to check education, malpractice history, license, training, etc. 
  • Also, check the board certification, SSN death master list, and health plan-specific requirements. 

They will ensure the accuracy of the data of credentialing professionals, who tell the healthcare organization the person is fit, healthy, and fit for the role. The data collection shows all the capabilities of the Provider. Credentialing provides the medical credentialing services that ensure the accuracy of the Provider's data for the leaders of administrative roles and committees for the further process. 

If any of the above steps are missing or not completed, the Provider credentialing can be delayed and denied. The errors in the medical transcription services could be costly for the organization, and they have to start the whole processing, which is very expensive. The errors in the medical transcription services have to start over the entire process again, and it can also eliminate the applicant from the desired position. Mistakes can slow down the Provider's credentialing, Billing, and negative revenue cycle. The Provider credentialing makes sure all the information is verified and avoids any gaps or incomplete information of the applicants. 

Who is responsible for credentialing?

There are two parties, one is provider organizations, and the other one is private payers, both of the parties perform the credentialing but in different ways. 

  • For private payers: it includes UnitedHealth, Cigna, Humana, whereas for Government payers, which consists of the Centers for Medicare & Medicaid Services, credentialing helps adjust the number of providers to determine the qualifications providers. 
  • For Healthcare systems and Hospitals: credentialing is used to enroll the providers to the panels for the high reimbursement of the services. It also gathers the data for the clinical privileges delineation.

Providers also play an essential role in credentialing. They can take many steps, including: 

  • Complete their required education for the future role
  • Work under the specialty training and gain the required skills which need to perform in their profession
  • A license issued by the Government-state or from that specific organization
  • Applied/Affiliated with the healthcare organization where they want to practice.  

What is the purpose of Provider credentialing, and why is it done?

Provider credentialing is basically for the patient. For the Provider' safety, they should work in a safe environment with a high-quality atmosphere. This process is all about ensuring a professional healthcare environment, a friendly and safe environment for all the healthcare staff and clinical fellows. Without the credentialing process, healthcare organizations can be penalized or legally sued because it is the utmost requirement by the State of Government. After two years, providers are re-credentialed, their competence and performance are evaluated at regular intervals to inform the competence decisions for the future. 

There are specific benefits that should consider, and the provider credentialing process should follow these ways:

  • Credentialing is going paperless
  • Payer enrollment and credentialing integration
  • Credentialing data is the source of truth for more users
  • Cloud technology aids remote credentialing work

Final Verdict about Provider credentialing!

Every healthcare organization aims to provide the highest quality, safest environment and protection to their patients. The Provider Credentialing process gathers hundreds or thousands of main informative elements such as data review, report survey, and assessments. The errors can impose heavy charges on the providers, organization, and patients. Various organizations share the same obligation to follow through on this objective. By reading this article, one can completely get what Provider credentialing is and why it is so significant; following the credentialing practices guarantees that medical credentialing services are taught and prepared to give quality care to the patients. UControl Billing is the most incredible outsourcing medical billing company that provides the best medical transcription services and all sorts of medical Billing, credentialing, and coding services. 

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