Credentialing

Physicians and other healthcare providers, including hospitals and facilities that want to bill an insurance company and receive reimbursement for services as an in-network provider, must undergo a process of credentialing. This process is called medical credentialing or insurance credentialing. Both medical credentialing or insurance credentialing or provider enrollment are used interchangeably.

Employing excellent medical staff is crucial for success of the healthcare organization. The healthcare institution must have medical bylaws that define the minimum credentialing and privileging requirements to validate the competency of healthcare providers. Previously, only hospitals performed credentialing; however, today, almost all healthcare facilities, ambulatory care centers, long-term care institutions, and even urgent care clinics do so.

During this process, insurance companies verify the provider's education, training, experience, and competency. In order to start this process, the provider must submit a credentialing application that details their training and qualifications to treat patients in their area of specialty. While large hospitals and health systems use their own credentialing team to perform this most group practices and solo practitioners use credentialing companies to complete the paperwork which is quite complex at times. To speed up the credentialing process hospitals and healthcare systems outsource this section of their enterprise. Outsourced medical billing companies [1] offer services that are low-cost and time-saving. As professionals complete the process reduces the chances of rejection.

Once the verification is complete, the insurance company then decides if the provider meets their internal qualifications to serve as a provider of services to their insured members. After approval of a provider's credentialing file, the insurance company then issues a participating provider contract that allows the provider of services to bill the insurance company and receive reimbursement as an in-network provider of services. Failure to complete the insurance credentialing process will result in the provider being paid as out-of-network for services rendered. There is more out of pocket costs involved with out of network providers so more and more physicians get in to network with insurance companies. Insurance credentialing typically takes 2–4 months depending on the payor.

Typically credentialing is needed for the following providers

• Physicians MDs, DOs
• Dentists
• Physical Therapists,
• Speech Therapists
• Psychology Counselors
• Occupational Therapists
• LMFT
• Group Medical Practices
• Clinics
• Hospitals
• DME Companies
• Home health agencies

Most providers who see Medicare and Medicaid patients must be credentialed in order to be reimbursed for their services. Some state Medicaid have MCOs (managed care organizations) where providers have to be credentialed with Medicaid before getting credentialed with MCOs.[2]

Telemedicine has become vital during and after the Covid-19 Pandemic. As healthcare delivery evolved, some physicians are now permitted to practice telemedicine under certain conditions[1]. For Example, Radiologists can sometimes help emergency rooms by reviewing CT scans or questionable x-rays taken during the night. Medicare and Medicaid Services allow healthcare institutions whose patients receive telemedicine services to grant privileges and credentials to some physicians who provide ambulatory surgery care and teleradiology. It is noted that the majority of licensing boards do not allow the prescription of controlled substances or the examination of patients via telemedicine. Because telemedicine has the potential for abuse, hospitals must have a specific standard. Many insurers and state licensing boards only agree to telemedicine practice if accompanied by oversight. The Reimbursement for telehealth services becomes part of the Revenue Management Cycle and Accounts Receivable of a Hospital or individual.

TJC (formerly known as JCAHO) was founded in 1951 and accredits and certifies healthcare organizations to meet quality standards. It envisions a future in which TJC is "leading the way to zero," which translates to zero harm in healthcare.

TJC, or the Joint Commission,[3] accredits and certifies over 22,000 healthcare organizations and services in the United States. TJC accreditation establishes a baseline for patient safety and process improvement. Because most state governments in the United States will not reimburse Medicare and Medicaid services unless accredited by the Joint Commission, successful TJC accreditation is critical for any healthcare entity accepting payment from government programs.

Credentialing [4] requires more comprehensive data of the professional, political member or a group of professionals. The process of credentialing includes verification of the information such as:

• Education and training
• Residency
• Licenses
• Specialty certificates
• Qualifications
• Career history

There are three types of Credentialing

• Personal Credentialing
• Political Credentialing
• Paperless Credentialing

Personnel credentialing is typically undertaken at commencement of employment (initial application) and at regular intervals thereafter (reappointment). Credentialing of vendors or other organizations may begin prior to the purchasing process and be repeated regularly.

Political parties credential delegates at their conventions. Credentialing is required for the UN representatives in the General Assembly. A Credentials Committee[5] consisting of nine members is appointed at the beginning of each regular session of the General Assembly. The Committee reports to the Assembly on the credentials of representatives.

Paperless credentialing is the process of doing credentialing through a software package. With the internet, many web-based programs have been created to help automate the process of paperless credentialing.

Some of Credentials verification Organizations in healthcare industry are as follows

• National Practitioner Data Bank
• The American Board of Medical Specialties
• American Association of Nurse Practitioners (AANP)/American Nurses Credentialing Center (ANCC)
• The Office of Inspector General (OIG) and the System for Award Management (SAM)
• Medical Board of Each US state

• Medical credentials
• Economic credentialing
• Actuarial credentialing and exams
• License
• Certification
• National Association Staff Services