If you are planning to start an independent medical practice, then it is necessary to get credentialed with insurance companies to submit claims and get reimbursed. Insurance credentialing is a complex and time-consuming process. Therefore, a thorough understanding of requirements and compliance with necessary guidelines is important to avoid delays. Credentialing is important if you want to work with insurance companies. Without insurance credentialing, providers cannot bill payers for medical services. This leaves patients behind, unable to use their insurance.
The long duration for credentialing matters for providers, and they should apply for credentialing on time to start a medical practice. In this guide, we will discuss how long credentialing takes with an insurance company and what various challenges providers face during this process.
What Is Credentialing with Insurance Companies?
Credentialing refers to the verification process in which the evaluation of a provider’s educational degrees, medical license, and training certifications is done to check their legitimacy. Credentialing defines whether providers are educated enough to treat patients or not.
This process holds significance in the healthcare industry as it is directly linked to patient safety. Only credentialed providers are allowed to treat patients and bill for their medical services. Credentialing with insurance companies is also strictly recommended to comply with legal rules and regulations. Patients also show trust in credentialed medical professionals, and providers can get access to large patient volumes in this way. Huge revenue generation and financial stability are guaranteed for credentialed providers.
How Long Does Credentialing Take With An Insurance Company?
Generally, credentialing takes 90 to 120 days, but the exact time duration depends on various factors. Provider’s readiness and type of payer matter a lot in determining the time duration for insurance credentialing. Incomplete or false information, low payer efficiency, and use of orthodox credentialing can be the roadblock in this process. Below is a detailed breakdown of the credentialing process to understand the process timeline:
1. Preparation Stage
This stage refers to the documentation gathering, CAQH profile formation, and application filing. The preparation phase typically takes 1-2 weeks, and it solely depends on the provider’s efficiency. All the necessary documents, including educational degrees, working licenses, malpractice insurance certifications, NPI numbers, training proofs, and compliance proofs, should be gathered beforehand.
The next step is CAQH profile completion. CAQH is a platform where all healthcare professionals make a profile and fill in their personal and professional information. This information is accessible to the insurance companies to use for verification purposes. Providers need to fill in accurate data in the credentialing application form. After application filling, recheck it to avoid mistakes.
2. Submission Stage
Application submission, receipt acknowledgment, and initial review are basic steps in this stage. These protocols require 2-4 weeks for completion. Once all documents are submitted and the application is filled, providers need to submit applications to insurance companies manually or online. Online way is speedy and reliable.
Initial review is done by the payer to ensure that all necessary credentials are attached. This preliminary review ensures that everything is in adherence with requirements. Payers share receipts with the providers with a unique reference number. This reference number can be used to track the status of credentialing applications.
3. Verification Stage
This is the most important phase which determines the result of the credentialing application. It takes 30-90 days as it involves complex processes like primary source verification and background checks. All the degrees, certifications, and licenses are verified by contacting the issuing bodies. If issuing bodies do not reply on time, then the time duration is increased in the verification stage.
Background checks are necessary to rule out any disciplinary actions, lawsuits, and malpractice claims. Background check ensures patient safety in the healthcare sector. In case of any missing information, credentialing boards can ask for additional documentation. Therefore, providers need to stay vigilant for objection clarification.
4. Approval Stage
After documentation verification, the process moves to the approval stage in which the credentialing committee reviews the application and gives the final decision. In case of application rejection, providers are informed about the denial and the reason behind it. If the application gets accepted, then providers are included in the payer’s network, and mutual contracts are signed. While contracting, providers and payers decide reimbursement terms and rates.
Common Challenges in Credentialing
How long does it take to get credentialed with insurance companies? It is difficult to predict the exact time duration for insurance credentialing as various factors affect the efficiency of the process. A few roadblocks are explained below:
1. Incomplete Application
This is the common error providers make while filling out the application form. Unintentional omission of any information can lead to application rejection or process blockage. Sometimes, providers submit expired certifications and licenses, which hinders the processing. Submission of outdated malpractice certifications is also reported multiple times by credentialing committees. Therefore, the CAQH profile is recommended and used these days to avoid such mistakes.
2. Verification Delays
Primary source verification depends on third parties because each educational and license institute has its different processing timelines. If these institutions do not answer on time or they have a large processing time, then a delay in verification is obvious. To overcome these issues, credentialing boards must have strong relationships with institutes to make PSV speedy.
3. Backlog of Application
Credentialing boards have limited faculty and technology and they can’t handle high application volume. High application volume leads to more processing days. So, if you have submitted an application at the start of the fiscal year or residency completion time, then be ready to face delays. It is wise to submit an application as soon as possible to avoid a rush.
4. State-Specific Regulations
Providers can get surprises in the form of additional documentation requirements from the insurance companies during the credentialing process. Some states have protocols to submit additional certifications and licenses to undergo a credentialing process. Getting such documentation is complex and time-consuming, leading to delays in the completion of the preparatory phase. Do thorough research about state-specific guidelines before starting the process and gather all necessary things timely.
Streamline Your Credentialing Journey
Providers should take necessary measures to avoid delays and get done with credentialing quickly and smoothly. Some suggestions are given below to streamline your journey:
1. Stay Organized
Make a checklist of required documents and gather them. Providers should save documents in cloud-based storage systems to make documents accessible every time. Reminders can be set for documentation expiration dates to remain updated with their status.
2. Use of Technology
Providers and credentialing boards should avoid conservative methods and leverage new technology to make the process fast and smooth. Providers can use tools that automate the submission and track the application. CAQH ProView and IntelliSoft are also useful tools in this regard.
On the other hand, credentialing boards should use new technologies like AI, electronic health records, blockchain technology and automation tools to lessen the time duration for insurance credentialing.
3. Hire Credentialing Experts
Insurance companies have to deal with other administrative tasks other than the credentialing process. Therefore, it is recommended to hire a third party for credentialing processes. Third parties have expert teams that ensure the accuracy of the process, find potential mistakes, and rectify them on time. Third parties help to reduce administrative burden and save resources.
Providers can also consult with credentialing experts if they are facing any issues with documentation and application submission.
4. Be Proactive
Providers should start the credentialing process about 4-6 months before starting seeing patients because providers can render medical services until they are credentialed.
Providers need to develop communication bonds with insurance companies which helps to resolve problems at once. Good communication bond also helps in deciding reimbursement rates after credentialing is done.
Conclusion
Insurance credentialing is an important step in getting reimbursed for medical services providers rendered to patients. But how long does it take to get credentialed with insurance companies? It typically takes 90 to 120 days, but the time duration can vary depending on several factors. There are some phases involved in the credentialing process. Starting with the preparation stage, 1-2 weeks are spent gathering necessary documentation and filling application forms manually or on CAQH ProView.
T
he submission stage follows the preparation phase, which involves submitting an application and receiving a receipt with a reference number. The verification stage takes most of the time as it involves PSV of documentation. It takes 30-90 days. The last milestone is the approval phase, which decides the future of the provider with the insurance company. Staying organized, hiring an expert team, and using modern technology can streamline the credentialing process and reduce the time required to process it.
FAQ - People Also Asks
Insurance credentialing is a process through which insurance companies ensure that healthcare providers have adequate qualifications to serve and treat patients. Insurance credentialing is necessary to receive payment for the rendered services.
Credentialing is important as it ensures that providers are well-educated and skillful. It shows healthcare standards are properly met which helps to build trust with patients. For providers, credentialing is the key to billing medical services provided to patients.
You can start with gathering necessary documents like licenses, certificates, and degrees. Create a CAQH profile and submit the application to the insurance company. Providers need to stay updated with application status.
Credentialing cost depends on the type of payer and state. On average, $200 to $400 is the credentialing fee per provider. State-specific fees and the number of insurers involved can influence the fee structure.
Insurance credentialing allows the practice to bill for medical services and grow financially. Providers can get access to a large pool of patients when they are included in the insurance network. Credentialing also enhances the repute and credibility of medical practice.
Physician insurance credentialing is a verification process to evaluate the degree, certifications, and licenses of a doctor to check their legitimacy. Physician credentialing allows doctors to join the insurance network and get reimbursed in return for medical services.
$200 to $400 credentialing costs per provider in many states of the USA. It depends on several factors like type of healthcare provider and type of insurance company. State-specific fees also influence credentialing costs, and providers need to keep in mind the state in which they want to start practicing medicine.
There are two ways to handle insurance paneling for your employees. Do it in-house or hire credentialing experts to credential all the providers. Hiring credentialing experts is wise if you are dealing with a large number of applications, as they make the process quick, error-free, and smooth.
Accuracy and customer service should be the top priority to look for in insurance credentialing reviews. The ability to address and solve complex credentialing problems can also be a key indicator of good service.