Credentialing New Providers? Don’t Forget These Crucial Steps

Adding new providers to your practice brings growth opportunities, but also important billing considerations. Navigating payor credentialing, enrollment paperwork, and proper system setup keeps revenue flowing smoothly for new clinicians.

We expose the key steps medical billers / credentialers should take when onboarding new providers to ensure claims pay as expected.

Why Provider Credentialing Matters

Credentialing verifies that providers meet minimum requirements to bill payers for services provided to their members.

This mandatory process, required by health plans and CMS, confirms details like:

Current licensure and certifications
Hospital privileges in good standing
Clean sanctions and exclusion records
Malpractice insurance coverage
Valid DEA and NPI numbers
Board certification status

Proper credentialing gets new providers networked with payers so they can be reimbursed. It also reduces claim denials and avoids enrolling providers with excluded statuses which leads to fines.

Main Steps for Credentialing New Providers

Here are key tasks for credentialing new members of the care team:

Pre-screening – Gather details early on expected privileges and documented qualifications. Identify missing items.
Payer enrollment – Submit provider enrollment paperwork per payer guidelines.
Background checks – Verify board certification, license status, sanctions, and malpractice coverage.
Data gathering – Get NPI, tax IDs, CAQH profiles, and other documents.
Group linking – Connect new provider to billing tax IDs and existing roster.
EHR updates – Add provider details like NPI that carry through to claims.
Confirmation – Validate successful completion of payer enrollment and privilege granting.
Billing system changes – Link the provider to payer fee schedules, enrollment rosters, and reimbursement rules.

Credentialing can take 60-90 days so starting early prevents claim denials later for unenrolled providers. Payers may allow back billing but it still disrupts cash flow. Check local guidelines as some states have shorter time windows.

Top Enrollment and Data Gathering Tips

Follow best practices for efficient enrollment:

Verify with CAQH profiles if possible to reduce duplication. Update expired documents.
Use provider enrollment management tools that populate most documents and forms for signing.
Look for bulk enrollment options to onboard multiple providers at once with major payers.
Have providers complete data sheets listing key identifiers needed (NPI, SSN, CAQH ID, etc).
Request potential exclusion waivers upfront if credentialing flags any issues for faster processing.
Photocopy taxi IDs, medical licenses, DEA certificates, and malpractice insurance cards for initiation.
Double check effective dates, rosters, specialties, facilities linked and billing relationships as you submit enrollment paperwork.

By centralizing data gathering early on it prevents having to track down elements later that delay credentialing.

Streamlining with Electronic Solutions

Leverage technology to reduce labor-intensive paperwork.

Technology options include:

Electronic credentialing vendors that interface enrollment data directly with payers.
EHR integration with credentialing software to sync key identifiers, simplifying form population.
e-signature tools for providers to approve forms remotely.
Automated credentialing status checking.
File transfer protocol (FTP) to send supporting documents to payers directly from platforms.
APIs that allow seamless data integration across systems.

Tools like CAQH ProView also allow providers to update information universally reducing duplication across payers.

Best Practices for Payer Outreach

Payer requirements vary so follow these tips for efficient outreach:

Verify which plans each provider should enroll with based on anticipated patient mix, specialty, locations, and networks.
Ask about payer-specific documentation requirements like practicing history and malpractice details early on.
Determine if payers allow retroactive enrollment and how far back.
Request fee schedules and benefits catalogues reflecting new providers’ reimbursement.
Inquire about appropriate effective dates for enrollment based on expected hire date.
Send prefixed rosters indicating which providers link to each billing tax ID.
Follow up on pending or incomplete applications to monitor status.

Thorough payer outreach prevents missteps that slow the enrollment timeline and creates transparency into requirements.

Billing System Updates for New Providers

To ensure accurate claim generation, update key system areas:

Claims

Link provider NPI and credentials to payer plan rosters
Append specialty, taxonomy codes
Assign provider to locations and bill groups

Charges

Load fee schedules, reimbursement rates
Add procedure-specific restrictions
Designate authorized diagnosis codes

Eligibility

Indicate providers participating with each plan
Identify non-covered services
Load patient panels for PCP assignment

Authorization

Denote services requiring approval
Link approval workflows

Reporting

Set profiles displaying relevant metrics

Updates prevent errors like submitting with the wrong provider ID number or billing for unauthorized procedures.

Go-Live: What to Do After Credentialing Completes

Once applications are approved:

Validate providers show enrolled within payer directories and portals with accurate profiles. Report needed corrections.
Confirm reimbursement rates loaded match amounts in payer fee schedules.
Submit test claims for newly set up providers to confirm clean claims processing end-to-end before live billing begins.
Check for successful arrival of printed provider welcome packets, directories, etc.
Distribute materials like roster summaries to front desk on new provider details and coverage specifics.
Set a reminder to begin provider re-credentialing 5-6 months before current term expires.

Avoid assuming enrollment details are accurately reflected across systems without validating. Spot check for problems to prevent disruptions.

Reassess Workflows for New Providers

Adjust workflows to fit new provider preferences:

Verify locations, call coverage and EHR access settings.
Update visit type time increments and schedule templates.
Check prescription preferences are configured (digital, printed, default pharmacies).
Set up templates for charting preferences, standard orders, and billing-related documentation specifics.
Confirm order entry workflows for tests, procedures, DME.
Enable appropriate prescription, lab and consult order integration.

Getting clinical and administrative workflows aligned upfront enhances productivity and billing accuracy.

Special Enrollment Considerations

Some situations require extra steps:

Out-of-State Providers – Enroll separately with in-state payers even if already enrolled where licensed.
Recent Graduates – Might have delays getting fully licensed if not completed during residency. Confirm Board eligibility.
Hospital-Only – Requires separate enrollment and credentialing from regular outpatient providers.
Locum Tenens – Needs enrollment under substitute physician rules.
Teaching Physicians – Add residents under supervision following payer guidelines.

Watch for red flags that complicate or prolong the enrollment process. Proactively addressing anomalies prevents problems.

Staying Organized Across Multiple Providers

Handling credentialing at scale takes diligence:

Use a centralized compliance calendar reminding when actions are due like recredentialing.
Store key documents in accessible, structured online repositories versus scattered folders.
Log all enrollment applications, dates submitted and approvals in a tracking matrix.
Note provider-specific requirements or exceptions like non-standard fee schedules.
Automate reminders on expiring licenses, DEA, insurance cards, etc.

Detailed tracking protects productivity when credentialing numerous providers simultaneously.

Watching for Provider Enrollment Red Flags

Be alert for situations that raise scrutiny:

Adverse background check findings like sanctions or exclusions.
Complicated prior practice history with gaps.
Multiple malpractice cases or large settlements.
Medicare opt-out without valid opt-out affidavit.
Disciplinary actions by regulatory boards against license.
Frequent malpractice carrier changes.
No solid justification for out-of-network status.
IRS tax issues (liens, unpaid taxes, etc).
Newly formed entities like practices without established FEINs.

Detecting concerning patterns early allows quicker mitigation or avoidance.

Auditing the Provider Enrollment Process

Regular audits help strengthen credentialing:

Verify all providers are enrolled with major payers tied to regular patient volume.
Confirm enrollments remain current and providers recredential before expiration.
Review monthly EOBs for denials related to “provider not enrolled” or invalid credentialing.
Compare enrollment details in billing systems to confirmers from payers like effective dates and fee schedules.
Ensure providers undergoing termination are disenrolled with payers.
Check that new providers are linked to appropriate TINs and bill groups.
Validate embed specialty taxonomy codes in claims where required.

Routine audits identify gaps in enrollment workflows proactively versus reacting to problems.

Staying on Top of Credentialing Changes

Keep current by:

Reading carrier bulletins and newsletters that announce changes.
Attending payer webinars detailing new initiatives.
Monitoring blogs or forums of billing/credentialing specialists.
Establishing open lines of communication with provider relations reps.
Participating in industry organizations like the American Association of Healthcare Administrative Management (AAHAM)
Studying reports from billing or credentialing vendors that identify trends.

Proactive education helps your team adopt changes smoothly and avoid falling behind.

Summary

Handling provider credentialing thoroughly prevents avoided revenue and payment delays when adding new clinicians. Allow ample lead time, gather documents proactively, enroll early with payers, and integrate providers correctly within billing systems. Solid organization and efficient workflows take the complexity out of scaling enrollment. With the right protocols and controls, your billing / credentialing team can take provider growth in stride.

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