Credentialing

Overview:
Provider credentialing is a complex, ongoing process and critically important. Without successful credentialing, provider reimbursement for medical services can be delayed or denied.

Even after submitting the myriad documents and forms to a variety of third parties to verify your credentials, please do not think that you are done. You will find that the process consumes hours and hours each year, particularly if you have adopted an inefficient process. The typical physician spends more than three hours annually submitting nearly 18 different credentialing forms, with staff spending an additional 20 hours.

Although a growing number of payers use the CAQH Universal Provider Datasource, and credentialing software can reduce the paperwork, most practices still manage this information manually. The process is far from flawless, and an increasing amount of practice staff time is spent researching, responding, and maintaining credentialing-related files for providers.

The provider enrollment processing time varies by payor. Some commercial plans take as long as 180 days to complete the credentialing process and then another 30 – 45 days for contracting, while others have the entire credentialing and contracting complete within 90 days. When submitting documents for enrollment, contracts, or following up on applications, it is important to document your steps, phone conversations with agent names, phone numbers, and tracking ID.