Notify each payer as soon as the change happens. Update CAQH, licenses, and tax records with matching information. Keep legal proof of the name change on file. Alex J. LauCo-Founder and COO of Medwave, bringing more than 30 years of hands-on experience in healthcare revenue cycle management, payer contracting, and medical credentialing. www.linkedin.com/in/alexanderlau/
Yes, many payers will credential locum tenens providers. Requirements vary by payer and time period of service. Always confirm the payer’s rules before scheduling. Alex J. LauCo-Founder and COO of Medwave, bringing more than 30 years of hands-on experience in healthcare revenue cycle management, payer contracting, and medical credentialing. www.linkedin.com/in/alexanderlau/
Delays usually come from missing information, expired documents, or slow payer review. Work history gaps and primary source verification can also slow things down. Clean submissions reduce most of the wait. Alex J. LauCo-Founder and COO of Medwave, bringing more than 30 years of hands-on experience in healthcare revenue cycle management, payer contracting, and medical […]
Start early and submit a complete application the first time. Keep CAQH, licenses, and supporting documents current. Follow up with each payer regularly. Alex J. LauCo-Founder and COO of Medwave, bringing more than 30 years of hands-on experience in healthcare revenue cycle management, payer contracting, and medical credentialing. www.linkedin.com/in/alexanderlau/
Multi-state credentialing requires systematic tracking of state-specific requirements. Each state has its own medical board, licensing requirements, and renewal timelines. Providers need separate licenses for each state where they practice, including telehealth services. Malpractice insurance must cover all practice states. CAQH profiles should list all state licenses. Some states participate in interstate medical licensure compacts […]
Expired licenses or certifications create immediate credentialing problems. Most contracts require continuous maintenance of all credentials as a condition of network participation. If a license expires, providers must immediately notify all payers and facilities where they’re credentialed. The provider may be suspended from seeing insured patients until licensure is renewed and verified. Claims submitted during […]
Hospital privileges and insurance credentialing are separate but related processes. Hospital credentialing grants permission to admit and treat patients at that facility, while insurance credentialing allows billing that insurer for services. Many insurance companies require active hospital privileges as part of their credentialing criteria, viewing hospital affiliation as validation of clinical competence. Loss of hospital […]
New practices encounter several hurdles including lack of practice history that payers typically review, no prior claim data to demonstrate volume or quality, longer approval timelines as new entities, potential delays in obtaining all necessary licenses and registrations, and difficulty demonstrating patient base without existing patient volumes. New providers should start credentialing applications 6-9 months […]
A credentialing committee is a group of professionals, typically within a healthcare organization, responsible for evaluating and verifying the qualifications of practitioners seeking privileges to practice at that facility. The committee reviews credentials such as medical licenses, board certifications, training history, work experience, and professional references to ensure that healthcare providers meet established standards of […]
Yes, Medwave can assist with credentialing transitions when joining or leaving a practice. When joining a practice, we help ensure your individual credentialing is transferred or established correctly with all relevant payers, update NPI and provider enrollment information, and coordinate with the practice’s existing payer contracts to add you as a participating provider. When leaving […]
Consistent underpayment requires systematic investigation and action. First, document the pattern by comparing contracted rates to actual payments across multiple claims. Review your contract to confirm the agreed-upon fee schedule and payment terms. Common underpayment causes include outdated fee schedules in the payer’s system, incorrect contract loading, bundling of services that should be paid separately, […]
Moving to a new state significantly impacts your credentialing because you’ll need a medical license in the new state before practicing there. You must notify all insurance companies and healthcare facilities where you’re credentialed about your practice location change. Most payer contracts are state-specific, so you’ll likely need to initiate new credentialing applications in your […]
Credentialing verifies that you have the appropriate education, training, licenses, and competence to provide medical care. Privileging grants you permission to perform specific procedures or provide particular services at a healthcare facility. While credentialing confirms you’re a qualified physician, privileging determines exactly what you’re allowed to do at a specific location. For example, a surgeon […]
Generally, you cannot bill insurance companies as an in-network provider until your credentialing is fully approved and effective. However, you may be able to see patients and bill them as self-pay or out-of-network during this period. Some insurance companies offer “interim” or “temporary” credentialing that allows you to begin seeing patients while full credentialing is […]
Maintaining credentialing status during evolving healthcare landscapes requires staying current with changing requirements. Many organizations have implemented temporary flexibilities for telehealth, cross-state practice, and documentation requirements that may continue or evolve. Keep all licenses and certifications current, even if renewal deadlines were extended. Maintain detailed records of any emergency privileges or temporary authorizations received. Stay […]
If your credentialing application is denied, you’ll typically receive written notice explaining the reasons for denial. Common reasons include incomplete documentation, licensing issues, malpractice history, or gaps in work history that weren’t adequately explained. You have the right to appeal the decision by providing additional documentation or clarification. The appeals process varies by organization but […]
Key mistakes include submitting incomplete applications with missing signatures or documents, providing outdated or expired documentation, failing to disclose required information (gaps in employment, malpractice claims, disciplinary actions), not responding promptly to requests for additional information, and missing critical deadlines. Also, avoid using inconsistent information across different applications, neglecting to maintain current contact information with […]
Recredentialing is the periodic review and renewal of your credentials to ensure ongoing compliance with standards. Most organizations re-credential providers every 2-3 years, with hospitals typically following a 2-year cycle and insurance plans varying between 2-3 years. The recredentialing process involves updating your application with any changes to licenses, certifications, practice locations, or incidents, and […]
Essential documents include current medical license(s), DEA registration, board certifications, CV with complete work history, medical school diploma and transcripts, residency and fellowship certificates, malpractice insurance declarations page, hospital privileges documentation, and Medicare/Medicaid enrollment information. You’ll also need to provide references from colleagues, complete background check authorizations, and may need additional specialty-specific certifications. Keep digital […]
Primary source credentialing usually takes 90-120 days, though it can extend to 180 days or longer depending on the complexity of your background and responsiveness of verification sources. Initial hospital credentialing often takes 120-180 days. Insurance payer credentialing varies widely, from 30-90 days for some plans to 120+ days for others. Factors that can delay […]
Medical credentialing is a process by which medical organizations verify the credentials of healthcare providers to ensure they have the required licenses, certification and skills to properly care for patients. It’s an essential function for hospitals and others which precedes hiring or obtaining coverage by an insurance carrier. Medical credentialing is perhaps most important because […]
Medical Credentialing is the process of contracting with Insurance companies in order to become an in-network or approved medical provider for that company. Becoming a participating provider for insurance companies in your area is an extremely important part of any medical practice. Whichever companies you are contracted with will dictate which patients you are allowed […]
Medical billing and credentialing for medical providers are two different categories in the healthcare world. Before any medical billing can even be completed, the healthcare provider needs to be credentialed with insurance companies in order to be an approved provider of services. Becoming credentialed as an in-network provider dictates the set amount of reimbursement that […]
Medwave and its team of medical billing and credentialing specialists understand the time and effort it takes to run an efficient medical office. That is why every office receives specialized attention and a tailored plan to help your practice succeed. Every contract is priced according to the needs of your practice and is always based upon […]
Providers and hospitals have many questions in reference to on-board medical credentialing protocol(s). The following blog post, Credentialing (On-Board Process for Providers, Facilities) discusses our overall protocol in detail. Alex J. LauCo-Founder and COO of Medwave, bringing more than 30 years of hands-on experience in healthcare revenue cycle management, payer contracting, and medical credentialing. www.linkedin.com/in/alexanderlau/
