Physician/Provider Credentialing: What is it and why is it Important?

by mgsi online Medical billing company

Provider Credentialing is the process of compiling and verifying complete information about a medical practitioner for the purpose of validating the physician’s expertise and ensuring qualitative service to patients. Physician Credentialing is a crucial step to get enrolled with any insurance company and to get reimbursement.

The process of credentialing is laborious and complex, which involves many paperwork and can take anywhere from 60 to 180 days or more depending upon the type of credentialing, the Payer chosen and the State. Read through the article for complete knowledge on Physician Credentialing.

Process of Physician Credentialing

The process of Physician Credentialing is a detailed step-by-step procedure of collecting, assessing and verifying the Medical Practitioners' credentials, documents and certification to ensure the physician meets the standard of quality patient care. Below is a checklist of documents that needs to be submitted along with the Credentialing application. Credentialing Applications are to be duly filled with all personal details, contact details and professional work history.

Physician’s current updated CV with exact beginning and ending dates of Medical Schooling, Residency, Internship, Work History, career gaps, etc.
Board Certifications and Professional school certification
Certification of completion for Internship, Residencies, Fellowship and all educational activities including CME’s (Continuing Medical Education)
Details of Hospital Affiliation and Privileges
Copy Professional License
Copy of current State Licenses
CAQH and PECOS Credentials
Copy of SSN and current Driving License
NPI – National Provider Identification
DEA, CDS and W-9 Form
Malpractice Insurance Certificates

Why is Physician Credentialing Important?

Credentialing with an Insurance Company is mandatory to enable the physician to be able to see the patients and get reimbursement from the Insurance. Insurance Companies may deny payments for Physicians who are not Credentialing with them. Physician Credentialing is also essential to imply the provider is legitimate and proficient, and showcase integrity to draw patients to your practice.

By getting credentialed with a payor, the provider gets increased patient visits from the network which indirectly reflects improved revenue for the practice.

Who needs to get Credentialed and When?

Any physicians who need to send their claims to an Insurance Company and get the reimbursement should get credentialed. Listed below are the various scenarios which require the physicians to look out for Credentialing Services.

New physicians who wish to start seeing patients
Providers who are joining a new practice/hospital
When switching employers
Shifting from one state to another
Those who get affiliated with new practices or groups
Physician looking to enroll with new payers

Providers are also required to maintain their credentialing privileges by re-credentialing on time to ensure the billing process is intact.

Physician Credentialing Services

Handling Physician credentialing without any prior experience can be difficult and may lead to multiple misses and rejections. A Medical Practice where one or more physicians are required to be credentialed will need expert support to handle and complete the credentialing process on time to ensure their claims are processed timely and cash flow is sustained. It can be laborious and complex for physicians to handle the credentialing by themselves along with the daily core of patient care, however, with an Outsourced Physician Credentialing, things are now easier and stress-free.

About MGSI

MGSI is a national Medical Billing and Revenue Cycle Management Service provider located in Tampa, FL. With over 25yrs in the Healthcare Industry MGSI provides the various scope of services right from End to end billing services and other services like Physician Credentialing, Practice Management, Healthcare Contracting, etc. MGSI has expertise handling credentialing Services with different payers and our Physician Credentialing team are experts in handling each application adequately to meet the elected insurance carrier’s requirements.