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Five Steps to Easy Physician Credentialing


Done haphazardly or postponed until a month before a new physician starts, sloppy credentialing can spell cash-flow delays and more. Here's how to do it right.

Credentialing is a necessary evil. Done haphazardly or postponed until a month before a new physician starts, it can spell cash-flow delays, scheduling nightmares, and other things that go bump in the night.

Fortunately, there are ways to minimize issues with credentialing. The following five steps are simplistic, yet proven.

1. Start early. Though most credentialing can be done within 90 days in many markets, give yourself at least 150 days. As payers have merged and supersized, a practice's ability to "pull strings" and expedite an application has shrunk. You are working on the timeline of someone else - the payer - and each payer has its own internal timeline for application processing. Give yourself some leeway.     

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2. Pay attention. Joellen Scheid, credentialing manager of Anthem for Virginia, says that 85 percent of applications are missing critical information that is required for processing. Missing, outdated, or incomplete information is most common in the following four areas:

• Work history and current work status (include the physician's effective date with your practice);

• Malpractice insurance;

• Hospital privileges and covering colleagues; and

• Attestations.

Scheid says that there is an abundance of information to demonstrate most credentialing delays can be avoided. Getting it right the first time means you'll get a new provider credentialed within 90 days, for most payers.

3. Stay current with CAQH. The Coalition for Affordable Quality Healthcare (CAQH) started its uniform credentialing program about 15 years ago. I know, as my practice was one of four beta sites nationwide. Since then, most payers in the nation have adopted this program. Physicians and incoming physicians who regularly update and attest with CAQH find credentialing and re-credentialing much easier.

4. Link a provider's start date. This one is a bit controversial - many practices are reluctant to possibly offend a new physician candidate by badgering him to submit the requisite credentialing paperwork. Still, I like contracts that link the physician's start date to the paperwork submission.  For instance, the effective date might be no sooner than 120 days of receipt of such information. It's better for the practice in the short run: it isn't scheduling around payers with which the new physician is not credentialed. And it's better for the new physician, whose schedule can be filled sooner and practice grow faster.

5. Know your state's regulations. Several states have their own laws for timely credentialing, including reciprocity regulations (if a physician is credentialed in another state by Anthem, for instance, her credentialing in your state can be streamlined) and in-state credentialing (a physician moving from one practice to another within the same state does not go through the full credentialing process again). Contact your medical society or state Medical Group Management Association to ensure you are using your state's standards to your advantage.

Credentialing is tedious, particularly if you don't have all the information you need up front. Make a strong first effort to gather all you need on new providers, and you will find credentialing to be much less painful than it might otherwise be.

Lucien W. Roberts, III, MHA, FACMPE, is assistant administrator of Gastrointestinal Specialists, Inc., a 21-provider practice in Central Virginia. In his spare time, he is a writer, speaker, and consultant. For the past 20 years, he has worked in and consulted with physician practices in areas such as compliance, physician compensation, negotiations, strategic planning, and billing/collections. He may be reached at muletick@gmail.com.

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