Becoming aware of becoming an independent medical practitioner is an exhilarating stage for the graduates and residents, but this change also comes with a major challenge: credentialing. This fundamental exercise helps in the validation of healthcare providers, verification of licenses, and authorization of these healthcare providers to provide care and collect reimbursements via insurance payers.
Learning how to credentialing new graduates may feel intimidating to many first-time providers. Whether it comes to time and paperwork or enrolling and selecting the right insurance and payers, every step is critical in the process of getting your career off the ground. In our blog, we will take care of assisting you in your credentialing process through the preparation, avoiding commonly made mistakes, and making a smooth transition to your first employment or independent practice, and getting all the credentials ready.
Timeline Before Graduation
To new graduates and residents, it is important to initiate the credentialing process as early as possible to avoid delays in commencing practice and reimbursement. Credentialing schedules differ; however, the process could be made smoother with proper planning.
12 to 18 Months Before Graduation: Take the Initiative to Prepare
At this point, it is time to go through the resident credentialing requirements. While you are unable to fully apply before earning your medical license, use this time to accrue the necessary materials, including medical school transcripts, letters about your residency program, and board exam information. An international medical graduate should earn his or her ECFMG certification as early as possible.
12-6 Months Before Graduation: Document preparation, collection, and scrutiny
Gather and prepare essential documents necessary in the credentialing process, including your graduation certificate or pending graduation letter, residency completion validation, up-to-date CV, and verification letters. This step is also great in ensuring that you are eligible to license and exams such as the USMLE or state-specific exams.
6 to 3 Months Before Graduation: Licensing and Applying
Most credentialing organizations seek evidence of an active license as a physician, and this is usually received upon or sometimes very near graduation. Within this window, you can apply to get your medical license and start on your credentialing applications with various payers as you wait to receive your licensure number. There is also a possibility of being subjected to a license pending status by some payers that can ensure a speedier enrollment.
With 3 Months After Graduation: Final Review and Approval
After all paperwork and licenses, and permits are met, credentialing committees confirm their validity. This normally will take 90 to 180 days on an individual basis, and according to organizational practices. Be receptive to demands of receiving extra information so as to avoid being delayed.
By becoming familiar with and following this schedule, new graduates and residents would be able to easily complete the credentialing process and be ready to enter independent practice with no employment or reimbursement gaps.
Documents to Prep
Proper development of accurate and complete documentation forms the baseline for first-job credentialing success for new graduates. Lack of or incomplete documentation is one of the most common delays and hold-ups in the credentialing process. By planning your documents early, you can save yourself a great deal of time and aggravation.
- Graduation Certificate / Diploma: This is your official certificate of completion of medical school or residency. If your diploma is not yet available when you apply, then a letter confirming that you are expected to complete your award and graduate can frequently be used temporarily instead.
- Residency Completion Letter: A letter from your program director or institution where you completed your training, verifying your residency or fellowship completion status, is essential to many credentialing applications.
- State Medical License: It is generally a requirement that you have your state medical license when credentialing. Certain payers will accept provisional or temporary licenses, but they will usually accept nothing less than an active license.
- DEA Certificate: DEA registration permits you to prescribe controlled drugs and is a credentialing requirement of most payers. It is important to have this early or obtain it early.
- Specialty Board Certification or Eligibility: If you have some form of specialty board certification or eligibility, some documentation of it can benefit your application and may be required of you depending on your field.
- Malpractice Coverage: Your malpractice insurance or coverage plan often needs to be made available before credentialing.
- Curriculum Vitae (CV): Your current curriculum vitae, including education, training, clinical experience, certifications, and any academic activities. This must be precise and well presented.
- National Provider Identifier (NPI): The NPI is an authorized identification number assigned to you for billing purposes and for verification by insurance providers. You are allowed to apply for an NPI before you graduate.
- Continuing Medical Education (CME) Certificates: These indicate commitment on an ongoing basis to professional education and maintenance of clinical knowledge.
Helpful Tips for Document Preparation
- Always maintain both electronic and hard copies of all documentation, which should be well-stored and categorised in folders.
- Where it is possible, use certified copies as opposed to originals to avoid the loss of important documents.
- Electronic credentialing systems are very common in many hospitals and healthcare groups; a scan of your files ready to upload will definitely make the process much faster.
- Contact your residency program administration/coordinator at any institution to determine what letters or verification forms are commonly required.
Choosing Payers
The new provider enrollment decision is one of the most self-limiting decisions related to credentialing, at least initially, with new graduates. This can significantly affect your revenue cycle and flow of practice.
Learn to Clean Practice Environment
- Hospital or academic center employment: In many cases, credentialing with payers will be done by the institution as part of its billing and compliance office.
- Private Practice: Joining a group or solo practice, you may need to enroll your own payers or assist the office manager/credentialing staff.
- Locum Tenens or Contracting Providers: In other operations, credentialing is handled by the contracting firm.
Typical Payers
- Medicare: It is equally important to enroll with Medicare in case you want to treat patients 65 years or above or accept payments over Medicare. It may be a long time till the application is approved (sometimes it may take 3-6 months).
- Medicaid: State Medicaid programs have a wide array of credentialing processes and timeframes.
- Commercial Insurers: Commercial insurers are Blue Cross Blue Shield, United Healthcare, Aetna, and Cigna, among others; they also each have separate credentialing offices and requirements.
- Workers' Compensation and Other Special Plans: These may be significant, depending on the demographics of the patients served.
Tips to the Payers
- Begin with those payers that benefit the greatest number of your expected patients.
- Follow the directions of your new employer, in case it have them.
- When dealing with a scenario where you are joining a private practice, enquire with the practice about the active, profitable payers.
Occasionally, it makes sense to approach a smaller payer first, then credential with the larger payer as you wait.
First Job vs Private Practice: Credentialing Differences
Your credentialing strategy will vary depending on whether you are taking your first job (e.g., at a hospital, large practice) or venturing off into your own practice.
First Job Credentialing
- Institutional Support: If you are employed by a hospital or large group, the credentialing department is there to do much of the work.
- Faster Payer Enrollment: These entities often have the capacity to quickly enroll you into payer networks due to volume contracts.
- Credentialing Specialties: In case of sub-specializing, your specialty verification and board certification documents might be required and or facilitated by your employer.
- Less Direct Responsibility: You are also usually required to submit the documentation, but do not bear the responsibility of the entire management of credentialing.
Private Practice Credentialing
- Full Responsibility: In self-practice or solo practice, you tend to do your own credentialing, whether of your own practice or one as a new compliant joining an established group.
- Varied Timelines: Enrolling as an individual payer can be more time-consuming, and you may have more than one different payer portal or system.
- Financial Impact: When it comes to credentialing, timing is everything, and delays have a direct correlation to your billing processes.
- Tools and Vendors: There are credentialing services and software that aid many new private practitioners in keeping track of provider applications.
Conclusion
Credentialing is a serious and often complicated venture when a new graduate and a resident leave for independent practice. Knowing the timeline, having all the documents ready carefully, and choosing the right payers strategically, you can make the process of becoming a fully credentialed provider as smooth as possible.
Licensing early, communicating with the licensing boards and payers in advance, planning, and preparing are the keys to not holding up a relocation to a hospital, large group, or making a new private practice. Keep in mind that credentialing is not just a checkbox on the way to a medical career, but a requirement that unlocks competent medical practice, payments, and professional growth. By planning and being persistent, you can successfully navigate the credentialing process and attend to what is important, offering quality care to your patients.
FAQ - People Also Asks
Can I credential before license issues?
Some steps of the credentialing process can be initiated prior to the issuance of your medical license, including compiling paperwork and submitting applications with a license pending status. Credentialing and enrollment typically demand an active, valid medical license.