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What are the major challenges in physician credentialing?

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Credentialing is the process of checking a provider’s competency, as demonstrated by education, training, licensing, and work experience. The Credentials Verification Organization will directly ascertain the medical provider’s education, training, licenses, work history and malpractice history.

Physician credentialing is essential to all parties in the healthcare industry. Hospitals and clinics are guaranteed quality care from the physicians they hire. Physicians, when credentialed, can become part of an insurance company’s network. Medical Credentialing assures patients that the healthcare industry is maintaining the highest standards of care.

Physician credentialing is a laborious and time-consuming process. As legal and financial issues are involved, the following significant challenges need to be eliminated for credentialing to be successful.

  1. 1) Up to date information necessary

Information on the application must be accurate and up to date. There is a rigorous process for provider credentialing with large amounts of data to be submitted. Even small changes like phone numbers or addresses must be re-attested in the CAQH database before an application can be processed. As medical professionals tend to move from one institution to another, it is necessary to keep track of these changes, so that information on applications is accurate.

  1. 2) Be aware of deadlines

A healthcare organization must be aware that an application review can take up to 3 months to be processed. Further, payors and other organizations that supply information required for the credentialing process have their timelines and standards. Hence it is difficult to say accurately when credentialing will be completed. Having software and procedures to handle credentialing will help reduce errors and to speed up the process.

  1. 3) Compliance with State regulations

Each state has its provider credentialing regulations and medical services policy guidelines. Also, CAQH has specified its requirements. This creates challenges in the medical credentialing process since the requirements vary from state-to-state and with changing policies and guidelines. The team handling the credentialing activities must keep track of all these requirements and changes. The software used must be suitably modified to cater to the unique needs of a state.

  1. 4) Getting peer reviews

Peer references are necessary for submitting the credentialing application. As physicians are busy professionals, it is prudent to fill up all the required details so that they are able to write the references/reviews quickly.

  1. 5) Regular re-evaluation

Credentialing is not a one-time process. There is mandatory re-evaluation every few years under the laws of the state. As a result, it is necessary to maintain records for all the checks conducted in the prior years to facilitate future verifications. This will be most helpful when a senior physician has to be credentialed as the information to be submitted would be enormous.

Bristol Healthcare Services, a medical billing company with over two decades of experience in the industry, has a team of experts with years of experience in credentialing. Our specialists will assist you in the intricacies of credentialing. We can also handle the entire credentialing process for you or your facility.

Even in the continually evolving healthcare industry, some things, like the need for comprehensive provider credentialing, privileging, and enrolment processes, remain constant. In today’s value-based environment, operational efficiency is vital. At Bristol Healthcare Services, we realize the importance of accuracy, completeness of information and speed. Our credentialing services have been honed over the years and we believe in taking the administrative stress off the shoulders of medical professionals.

Allow us to assist you with a mutually rewarding partnership!