Credentialing Services
Get In-Network Status
Most insured individuals opt for and receive medical services from healthcare providers who are part of their insurance network, resulting in reduced out-of-pocket expenses. Being in-network with various plans offers numerous advantages, leading to increased revenue for both groups and providers. By having in-network status, providers can accommodate a larger patient volume as they become accessible to patients covered by multiple plans.
Additionally, being in-network attracts more referrals from fellow physicians who seek in-network specialists or primary care physicians for their patients.
Insurance providers themselves also refer patients to in-network providers, further boosting the patient flow and revenue for those providers.
Our credentialing services offer a comprehensive solution backed by an experienced team, a reliable methodology, a practical approach, and the utilization of state-of-the-art software. With our seasoned professionals, we ensure that every aspect of the credentialing process is handled with expertise and precision.
What Our Credentialing Offers
Experienced Team
We have a solid credentialing team that has proven results with verifiable references from past clients. Our Credentialing team have developed great relationships with most insurance carrier provider representatives to assist throughout the processes and frequently speeding up the process time from start to completion.
Practical Approach
We provide practices that we work with a shared folder where up-to-date information is available regarding the credentialing status for the group, as well as for each individual provider, as the completion dates will vary on a provider basis. We work very well with New Group and Provider set-ups as well as established groups.
Reliable Methodology
We methodically work to correct previous credentialing mistakes to ensure the providers are listed properly with payers for established groups where credentialing errors were made in the past by other credentialing companies or teams. Our team is able to file and obtain Group NPI’s as well as NEW provider NPI’s and CAQH Provider Profile creation. We manage CAQH Provider Profiles as well as maintain the Groups Availity Site information, keeping the providers in compliance
Technical Edge
We have software that we utilize at our cost that is 100% effective at tracking expirables. We notify providers in the beginning, 2 months before licensure, certification, or malpractice insurance expires. Second reminders are sent to the provider one month before and then again 2 weeks prior, as this is critical in maintaining in-network status with payers. Providers may be terminated from the network if these items are not renewed, updated, uploaded into CAQH, and re-attested.
Let’s Work Together
Whether you just need a nudge in the right direction or a full range of services to get your practice running smoothly, we’re here to help. Book your discovery call today!
FAQs
What is credentialing?
Credentialing is a systematic verification process used in healthcare to ensure professionals (doctors, nurses, allied health providers) have the education, training, licenses, and experience to safely and competently care for patients. It involves collecting and assessing documentation such as diplomas, board certifications, work history, malpractice claims, and state licensure. Credentialing is done at MHMC to allow a provider to be associated with a hospital or bill insurers. It’s a gatekeeping mechanism to maintain quality and safety in patient care.
What gets checked during a credentialing process?
During credentialing, various aspects of a healthcare provider’s background are verified including medical education, professional training (residency and fellowship), board certifications, state licensure status, work and malpractice history, peer references and any disciplinary actions, or sanctions. Also, DEA registration, NPI, and hospital privileges are reviewed. Verification is done through primary sources such as contacting universities, licensing boards, or previous employers directly to ensure accuracy and authenticity of the information provided.
What is required for credentialing?
To complete the credentialing process, a provider must submit a comprehensive application and a portfolio of supporting documents. These usually include copies of medical degrees and diplomas, state medical licenses, board certification documents, malpractice insurance coverage, work history details, peer references, and current CV. They may also need to provide identification, CME certificates, immunization, or health screening documentation. Timeliness and accuracy are key, as missing or incorrect information can delay the approval process.
What is the purpose of credentialing in healthcare?
Credentialing plays a critical role in safeguarding patients by ensuring healthcare providers are qualified and competent to deliver medical care. It helps healthcare organizations mitigate risks, uphold clinical standards, and comply with regulatory and accreditation requirements. For insurance companies, credentialing is necessary to validate providers meet the standards to participate in their networks and get reimbursed. Ultimately it supports trust in the healthcare system by confirming providers meet the legal and professional benchmarks expected in delivering safe and effective care.