Credentialing Made Easy

March 15, 2002

Easier ways to get credentialed and get paid

June Fabiano, who manages a four-surgeon practice in Glendale, Ariz., has seen it happen before: A new physician starts work only partly credentialed, or not at all. Starting out on such rocky ground can be problematic, for both the physician and the group.

"It's a mess," Fabiano laments. "Scheduling becomes a nightmare because staff can't consider all patients for the new physician's schedule. And things in the billing office get confused, too. Billing staff has to be careful that they don't accidentally bill an insurance plan the physician isn't credentialed with."

Whether you are adding a new doctor, or are a solo physician opening a practice, you need to start the credentialing process far in advance -- sometimes six to nine months before you plan to see patients, advises Kimberley Pollock, a Dallas-based consultant with the practice management firm Karen Zupko & Associates Inc. "Consummating health plan contracts can take time, and if you are not on the plan, you can't see its patients," she says.

Don't let this happen to you or your practice. If you or your physicians want to get paid you must be credentialed; to get credentialed you need to plan ahead.

Get it together

A good system helps the credentialing process flow smoothly. Get organized and mobilize staff as soon as you know a new physician is coming on board -- or, if you're starting out on your own, as soon as you know where you will be setting up practice. Typically, physicians need a license and proof of malpractice insurance before they can get hospital privileges; and they need hospital privileges before they can be credentialed by the plans. Since some hospital committees only meet quarterly, it's critical to get the necessary paperwork in order well ahead of time.

"Because our manager started both the hospital and managed-care plan credentialing process months in advance, our new spine surgeon had a full appointment schedule on the day he began seeing patients," says Alfred Coppola, MD, of Bakersfield Orthopedic Medical Group in California. "We could bill and be reimbursed right away without any problem."

Coppola's practice manager, Diane Arechiga, credits her credentialing success to planning ahead. "While waiting for the hospitals to credential the new surgeon, I began obtaining managed-care plan applications," she says. Arechiga used a document management software program to manage the variety of plan applications she received. "After scanning each form, I can easily make changes, update information, and keep a new master copy of the application." This tactic saves significant time during recredentialing; Arechiga simply prints out the master form she needs.

Greg Hrasky, MD, a pediatric orthopedist relocating his practice from Wisconsin to Arizona, warns that the credentialing process is very labor intensive. "Every plan has a different application form," he says. "Completing applications and making phone calls can eat up hours of staff time."

In Fabiano's practice, the staff maintains individual hanging files with each physician's important documents. "I have someone in charge of the credentialing and recredentialing process and she keeps multiple copies of each document in her files. All she needs to do is fax or mail them as needed," Fabiano says.

Don't lose it

Managed-care plans are notorious for "losing" physician applications and other paperwork. Sue Parks, president of Parks Healthcare, a Phoenix-based physician billing and consulting firm, suggests mailing all materials "return receipt requested."

"That way, you can prove that someone received your materials," she says.In addition, it helps to have someone else review the application before sending it. "If you leave even one field blank, your application can percolate to the bottom of the pile," she warns.

If problems crop up, Parks suggests speaking to a manager at the managed-care plan, rather than a front-line employee. "If you build a relationship with someone who has authority, the chance of materials getting lost is lessened." Arechiga finds that hand delivering applications works well, too. "It helps that they put a face with a name," she says.

If materials do get lost, consistent follow-up helps. As Pollock suggests, "call the plan regularly and ask to speak with the same person each time. You want them to know your name."


"Despite our diligence," says Coppola, "a local plan with both an HMO and PPO lost the paperwork we sent for the PPO. Even though the PPO was in the same building as the HMO, we were still required to reapply, and the process took a year." Luckily, this plan didn't deliver a high volume of patients to the practice.

Hrasky had a different type of problem: "I got a call from a plan asking why none of my references had responded four weeks after the agency sent reference letter requests. When I investigated, I found that the plan had mailed the letters to addresses that were different from the ones I provided."

When Hrasky asked where the addresses were that he had sent in, the managed-care employee responded, "I don't know. These were the ones in our database." The lesson? Double-check all aspects of your applications.

The outsourcing option

Hrasky eventually gave up on doing the credentialing legwork himself and hired Parks' firm to help him. State medical societies and local hospitals can recommend firms to perform credentialing services. "Hiring an outside service was totally worth it," he says. Depending on what is provided, fees may range from $5,000 to $7,000 -- but compare that with the time an assistant or office manager must take away from her job to perform the function. Time spent on credentialing keeps staff from other valuable duties that, if neglected, could end up costing the practice.

"The cost of having staff do it adds up fast," says Hrasky. "Each hour they spend on paperwork takes them away from revenue-generating activities, such as claims follow-up, patient collections, or management duties." And the costs are minimal compared to the revenue that is lost when a physician's services aren't billable because he was not credentialed in time.

Hrasky says Parks Healthcare's credentialing manager, Cindy Leonard, is familiar with many local plans; she also uses software to streamline the process, which a solo physician like Hrasky typically cannot afford.

While manual systems may work for some, a large group may be wise to invest in software. There are a number of applications available; generally, users enter the physician information just once.

"The software automatically populates multiple application forms," says Leonard. This keeps her from completing the myriad of different forms from each plan. Another great feature, Leonard says is "you can set the software to remind you when a recredentialing deadline looms, so you have time to get your documents to the plan in time."

A drawback to many credentialing software packages is that they do not contain applications for every health plan in America. Before making a software purchase, compare the list of plans in your area with the list of applications the software includes. Also ask about the ability to add new forms. Some software companies allow users to fax new application forms to them, and they add them to the database.

By the middle of this year, the Coalition for Affordable Quality Healthcare (CAQH), a group of 26 health plans, hopes to offer an online database that links practices and plans. CIGNA, Aetna, FirstHealth, Great-West Life & Annuity Insurance Company, and a number of Blues plans are already involved. Practices will complete a registration application and fax copies of licenses and other credentials to a secure data center. Authorized plans can access the database for both credentialing and recredentialing purposes. Physicians can expect to pay about $5,000 or more for credentialing software, or a subscription fee for Web-based applications and CAQH's service.

Site visit possible

Although it is not typical for plans to require a site visit for initial credentialing, plan representatives may visit you during recredentialing --  or if the plan is experiencing problems with your practice.

To prepare for a site visit, contact the National Committee on Quality Assurance (NCQA) and request their site audit checklist. Most plans use it in their credentialing process.

Parks' advice is to take this visit in stride. "Primarily, you should make sure there aren't any glaring general liability issues. For example, if you are a pediatrician, make sure the reception area is devoid of dangers such as cactus or poisonous plants, and that safety plugs are in place." Parks also suggests making sure there are no drugs in exam rooms, samples are stored, and narcotics locked up.


"Keep the reception and clinical areas clean, and the chart room tidy," she adds. "Rarely do plans review charts during the initial credentialing process --  but do have your fire extinguishers ready. They always seem to check those."

Cheryl Toth can be reached at editor@physicianspractice.com.

This article originally appeared in the March/April 2002 issue of Physicians Practice.