Credentialing New Providers? Don’t Forget These Crucial Steps

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

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

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

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.

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.

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.

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

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.

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.

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.

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.

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.

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.

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.