Unlocking the Basics of Medical Credentialing Requirements

“Medical credentialing”: the tedious but necessary process of verifying a provider’s credentials, including license(s) and exclusion status, education, and training. This process ensures that providers in your organization have the qualifications to deliver quality care to your patients.

And as important as it is, medical credentialing, unfortunately, isn’t one-and-done at the time of hire. Healthcare organizations must regularly check practitioners’ qualifications and license status to comply with regulations and to ensure payment from private and government agencies like Medicare and Medicaid.

What are the requirements for medical credentialing?

A practitioner must submit several documents to start the credentialing process. Credentialing requirements vary by state, and the list below details the general documents required.  Additional documentation is often necessary as well. 

• Personal information 
• Continuing Medical Education (CME) record
• Curriculum vitae (CV)
• Disciplinary history with explanations
• Driver’s license
• ECFMG number, if applicable
• Immunization records
• Letters of recommendation
• Malpractice insurance and claim information
• Medicare and Medicaid ID numbers
• National Provider Identifier (NPI) documentation
• Professional diploma or certificate
• Proof of completion of internship, residency, and fellowship, if applicable
• Recent photograph
• Resident/visa status, if applicable
• State(s) license numbers
• Work history

How long does medical credentialing take?

Once the necessary documents are collected, the healthcare organization’s credentialing team screens this information against state and federal sources. For each provider, this whole process takes many hours to complete, longer if the provider holds multiple state licenses as each state board has to be checked. Delays, for example, due to missing documents or a slow response from a primary source, can extend the credentialing process by days and sometimes weeks. 

Think about all the time and resources that go into credentialing a single provider and multiply that by the number of providers in your organization. As you can see, medical credentialing is time and resource-heavy. 

Closed insurance panels: what does that mean?

Although most medical credentialing processes are straightforward, sometimes an inquiry may state that the insurance panel is closed. This means an insurance company has determined it has enough providers for a particular specialty and therefore closes the panel for credentialing additional providers. Instead, the insurance company will add the new provider as an out-of-network provider, potentially limiting reimbursement for services.

When this happens, healthcare organizations have two options: accept or appeal. Accepting the closed panel decision means your provider will remain out-of-network, with reimbursement dependent on the patient’s treatment plan. This makes determining the financial repercussions of this decision difficult.

The decision to appeal a closed panel decision could benefit patients and your organization but takes additional time and resources. An appeal package will improve your chances of success and should include the following:

• Provider information and credentials
• Equipment, tools, and procedures offered by the provider that may not otherwise be available in the patient’s service area
• A list of providers who can’t refer patients due to out-of-network status
• Physicians who refer to the provider
• Documentation of physician shortages to help demonstrate the need for the provider’s services
• Additional services or special hours the provider offers

Some panels remain closed despite your best efforts, but sometimes appeals succeed.

What is a credentials verification organization?

Some healthcare entities hire a credentials verification organization, known as a CVO, to manage their medical credentialing. Typically, CVOs are better equipped with the technology and automation to complete medical credentialing more quickly and efficiently than individual healthcare organizations. 

Credentials Verification Organizations conduct a thorough provider screening and license(s) verification using multiple primary source datasets on behalf of the healthcare organization. In addition, they can continuously monitor for sanctions, exclusions, debarments, changes in license status, and disciplinary actions against your providers. Depending on the CVO, additional services such as screening sex offenders and abuse registries may be available.

Due to their extensive screening, CVOs better protect patients from dangerous, fraudulent, or negligent practitioners. Credentialing services also help healthcare entities meet and stay compliant with credentialing regulations.

Verisys: the largest outsourced CVO in the U.S.

Here at Verisys, we make credentialing easy. Outsourcing your medical credentialing to Verisys saves your team administration time and resources while minimizing the risk to patients and your organization of hiring a sanctioned provider. 

We screen and regularly monitor all your practitioners against over 5,000 primary sources for license and exclusion status. In addition, Verisys keeps track of

✓  New or changes to government regulations

✓  License renewals, status changes, and expiration dates

✓  Federal and state exclusion list

✓  Documents required for credentialing

Our credentialing solutions can handle all your credentialing needs. Find out how easy it is to outsource your medical credentialing with Verisys.