What is Physician Credentialing?
Physician Credentialing is a process and practice of verification and accreditation of a healthcare provider with a Payer, which in turn affects healthcare billing and the physician billing. The main aim of physician credentialing is to verify and rank a doctor on the basis of his license, training, experience and track record of delivering quality healthcare to his patients.
What is the Importance of Physician Credentialing?
Physician Credentialing gained popularity in the early to late 80s as the US Healthcare system developed the HMO and PPO model to counter the unchecked rise in the cost of healthcare delivery. The concept of a ‘capitated’ payment where the provider agrees to a lesser payment for faster processing of his claims and also access to a bigger patient population who are members of the payer – was a novel concept that was ‘win-win-win’ situation for all the parties – the payer, the provider and the patient.
- It is very important for a physician to get credentialed because this helps the physician in coming at par with different carriers of insurance.
- After the degree and license, being credentialed is one of the major criteria for a Provider to be successful financially.
- This also proves to be very helpful in determining and finalizing the medical billing of the patients. Credentialed Providers get into a ‘capitated’ agreement with the Payers.
- Though the ‘capitated’ payments might be lower, the Provider now has a wider range of patients that includes the entire membership of the payer in that geographical area.
- Appropriate Physician Credentialing by the payers ensures smoother claims processing during healthcare billing.
How physician credentialing is done?
The Physician to be credentialed either handles the process on their own or outsources it to a third party which does all the work related to getting the physician credentialed. The basic steps are:
- Filling up the appropriate forms
- Physician’s signature and attaching of relevant documents
- Mailing the application to the Payer/Carrier
- Follow-up for the receipt of the Forms/sending additional documents on request
- Getting the Physician Credentialed
Advantages of being credentialed:
There are several advantages including recognition and access to a wider cross-section of the patient population. The provider would be getting a lesser reimbursement on his medical billing and coding per patient. But, overall it is in the provider’s favor since he has a wider patient population of the payer to cater to and his reimbursements are also faster compared to the other Providers.
The Credentialing process is an annual one and the provider needs to get re-credentialed every year to continue in the ‘capitated’ program of the payer and derive the benefits on his healthcare billing for patients.
About the Author:
Tanya Gill is the Public Relations Manager for ecare India based in Chennai, India. She has wide knowledge and experience in the medical industry. ecare India is a leading medical billing company offering end-end medical billing, charge entry, healthcare outsourcing, physicians billing services and is backed by extensive domain expertise, latest technology and dynamic compliance norms. ecare is HIPAA compliant and is the first Indian medical billing company to get ISO 27001: 2005 certified for information security management. ecare is also ISO 9001:2008 certified for quality management. By providing outsourced medical billing services, ecare makes it feasible.