Requirements for credentialing with both governmental and private insurance have expanded over the years. It is vital to keep this information up to date and maintain your insurance credentials. Concierge physicians may not need to worry about this as much, but most patients want and need their insurance to cover their medical expenses. Likewise, physicians need to be compensated for their hard work.
It is very important that all documents are accurate and match one another. Problems begin when there are inaccuracies and discrepancies between various records. It is a good idea to contact your references before they receive a reference request, as problems can occur when professional references do not respond in a timely manner.
Forms and Documentation
Myriad forms and supporting documentation must be provided. The credentialing process is burdensome but with some careful planning, this can be managed. Most health insurance companies, however, are now using a centralized database. The Center for Affordable Quality Healthcare (CAQH) is a commonly used web-based credentialing service. The Universal Provider Datasource (UPD) used by CAQH is a repository for credentialing information. Once the data is collected, it is available to insurance companies.
Develop a Process
Just as with facility credentialing, make credentialing files maintenance routine. Because there is tremendous overlap in the requirements for insurance and facility credentialing maintaining one will help with the other. Keep copies of all pertinent data up-to-date and in a centralized location. Make sure to develop full
Build reminders for all submission dates into your calendar system, including recurring reminders to check the status of the National Physician Identifier (NPI), state medical license, board maintenance of certification status, malpractice liability coverage, Office of the Inspector General (OIG) sanctions exclusion database, and the National Practitioner Data Bank. Keep a screenshot of the search results as each of these are checked.
Credentialing applications usually require a large amount of background information, including complete education history with diplomas, work history, a current CV, board certification information including type and dates with supporting certificates, state licensure information with a copy of the license, malpractice liability coverage and certificate, state and federal controlled substance licenses and certificates, NPI, among numerous other items (See Table Below). Each physician and the practice as a whole need an initial checklist and a yearly
In A Practice Change
If you are changing practices or starting a new practice, do not assume that you will automatically be in-network for an insurance provider. It is better to assume you will not be. Contact each insurance carrier to determine your contract status and get instruction in writing about the steps for creating your credentials for the new practice. The process varies substantially between carriers.
Scheduling
The credentialing process may take several months. In some cases, companies may not even be accepting new providers. Do not take this at face value. If you are told the panel is closed, continue to apply every six months. Appeal the decision, especially if there are special circumstances such as being in an underserved area or providing specific services that are not readily available.
Conclusion
This process is of the utmost importance for your business. If you go months without being paid, you may lose staff, or the business itself. Careful planning and attention to detail are central to your defense.
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Table: Insurance Credentialing Information
| Name (exactly as it appears on license) |
| Previous /other names |
| Gender |
| Ethnicity |
| Date of birth |
| Social Security number |
| Mailing address |
| Email address |
| Daytime phone number |
| Citizenship information |
| Recent photograph |
| Center for Affordable Quality Healthcare CAQH PasswordEducation (undergraduate school, graduate school, medical school) |
| Copy of diplomas |
| Training (internship, residency, fellowship) |
| Copy of certificates |
| Work history for last 10 years |
| Hospital affiliations and privileges (past, present, and pending) |
| Current curriculum vitae (CV) |
| Board certification information including type and dates with supporting certificates |
| Continuing medical education (CME) documentation |
| State licensure information with a copy of the license (current and past) |
| Malpractice liability coverage and certificate (for past 10 years: agency, address, policy number, and group name) |
| Malpractice claims history |
| State and federal controlled substance licenses and certificates (DEA) |
| National provider identifier (NPI) |
| Educational Commission for Foreign Medical Graduates (ECFMG) Certificate (if applicable) |
| Copy of Bureau of Narcotics and Dangerous Drugs (BNDD) registration |
| Practice address |
| Practice tax ID number |
| Practice phone number |
| Primary practice contact |
| Practice specialty |
| Peer references (same degree and specialty notes with contact information) |
