Physician credentialing is a crucial, but often overlooked, aspect of the healthcare sector. It is essential to maintain accurate and up-to-date physician information to ensure that patients receive quality care. Mistakes during the physician credentialing process can have serious consequences, such as financial losses, delays in claim reimbursements, fines or penalties, exclusion from federally funded programs, and even harm to patients. Credentialing lapses can also expose a healthcare organization to malpractice suits and accreditation problems. Therefore, understanding the depth of the credentialing process and avoiding common mistakes is vital knowledge.
What is physician credentialing?
Physician credentialing, also known as medical or provider credentialing, is the process that validates physicians for delivering clinical care, wherein physician’s education, license, experience, certifications, affiliations, malpractice, any adverse clinical occurrences, and training are verified. It also involves conducting background checks and checking for any disciplinary actions against the physician. The physician credentialing process is important for both the physician and the healthcare organization, as it establishes trust between patients and physicians and ensures that only qualified physicians are providing care.
Who conducts physician credentialing?
In the United States, physician credentialing is typically done by various physician credentialing boards or organizations, both government and private, that establish these guidelines and physician credentialing criteria. For example, The Centers for Medicare and Medicaid Services (CMS) is a government organization that physician credentialing must adhere to in order to receive Medicare reimbursement. Similarly, The National Committee for Quality Assurance (NCQA) is a private physician credentialing organization that provides physician credentialing services to managed care organizations.
What is the typical timeframe for the physician credentialing process?
The physician credentialing process usually takes anywhere from 45 to 60 days, however, there is no defined time frame. It may take more or less time depending on the physician’s qualifications and the type of organization they are applying to.
What are some common physician credentialing mistakes made by physicians?
- Applying to the wrong organization: When applying for physician credentialing, you must first research and identify the right physician credentialing organization that you need to apply to. Each organization has different guidelines.
- Submitting outdated or expired credentials: It is essential to keep all your credentials, such as licenses and certifications, up to date. Outdated or expired credentials will not only cause delays in the credentialing process but may also lead to a loss of privileges.
- Incomplete applications: A physician credentialing application must be complete in order to be processed. Any omission of important information may lead to delays in the credentialing process or even a denial of privileges.
- Lack of communication: It is important to maintain open communication with the physician credentialing organization or board throughout the physician credentialing process to avoid delays.
- Treating Patients before Credentialing: In some cases, physicians may start treating patients before the credentialing process is complete. This can lead to problems if there are any delays in the process or if the physician is denied their credentialing.
- Not completing re-credentialing or re-validation: Physicians need to make sure they complete the re-credentialing or re-validation process on time to avoid any lapses in their credentialing.
- Not completing a background check: One of the most important parts of physician credentialing is the background check. Physicians need to make sure they complete this step to avoid issues later on.
What are the common physician credentialing mistakes made by healthcare organizations?
- Not conducting primary source verification: Healthcare organization must contact various sources, such as schools, hospitals, and state medical boards, to verify a physician’s credentials. It is essential to conduct primary source verification in order to validate a physician is who they claim to be and that their credentials are up to date.
- Relying on paper credentialing: With robust technology, such as iPatientcare, healthcare organizations can now utilize online physician credentialing systems which not only save time but also improve accuracy.
- Not having a system in place: Having an efficient physician credentialing system in place is essential for any healthcare organization. Without a proper system, it can be difficult to keep track of physician credentials and inaccurate credentials or a lapse in credentialing can occur.
- Not performing regular audits: Regular physician credentialing audits help to ensure that the physician credentialing process is running smoothly and that there are no lapses in the system.
Physician credentialing is an important process that should not be taken lightly. By understanding the importance of credentialing and avoiding common mistakes, you can help ensure that your practice or your organization runs smoothly and in compliance with all credentialing rules.
iPatientCare is one of the leading EHR vendors in the market & offers comprehensive Healthcare Technology Solutions designed to meet the needs of practices of all sizes. Our subject experts are always available to answer all your queries about the physician credentialing process to help you not make any mistakes.
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