Credentialing in healthcare is a process of reviewing physicians’ qualifications, experience, training, and licensure. It is a formal process that authenticates that the physician has the required education, training, and specialty certificates to provide care and have no malpractice history. Credentialing is a necessary process that is mostly initiated upon hiring or enrollment of a new physician. Hospitals and healthcare providers are legally bound to verify new physician’s NPI, CAQH, professional education, references, and certifications to make sure that their patient is getting medical treatment from the right provider. It also ensures that all the providers are compliant with the standards set by the regulatory organizations.

What is physician credentialing process?

The physician credentialing process starts with the collection of documents and actually applying for it. What is a credential? The physician credentials include professional details of the physician, past experience and other educational particulars, what’s a physician required to provide. The credentialing application is bundled with documents such as CV, government identification or driver license, national provider identification (NPI), license, certifications, professional references, and malpractice coverage.

Once the application is deemed complete and is thoroughly checked, it is submitted for review. If anything further is required or ambiguous, the representatives contact to collect that information and asks about what do physicians mean by it. If everything goes smoothly, the credentialing process completes in the due time and the result determines whether the physician is permitted to provide medical care or there are objections.    

Why is credentialing important for medical assistants?  

Medical assistants perform lots of tasks and duties at a healthcare facility which includes scheduling, insurance verification, lab management, answering phones, and other administrative tasks. At the front desk, they are mostly responsible for taking patient information, explaining things and making them ready for a medical checkup. Medical assistants also help in performing clinical tasks such as helping physicians in the exam room, taking lab samples and changing a dressing, etc. In fact, medical assistants mostly handle the operations of a provider and any negligence on their part can put a provider in trouble and health organizations are increasingly becoming the target of lawsuits. So credentialing is very important for medical assistants which makes sure that only certified and trained medical staff handles the care delivery process.    

Credentialing process in medical billing

Credentialing is an important part of medical billing. Medical providers are very concerned about the collections and revenue and credentialing makes sure that their payment claims are accepted without any objection from the payer or insurance companies. The medical credentialing process makes sure that only the qualified staff has handled the care delivery process and providers get maximum claim acceptance and reimbursements. This is what medical billing and coding is all about.

Medical billing and coding is a process of accurately transcribing the clinical information and making sure that providers get paid for the services they provide. If non-credentialed and non-contracted providers handled the care delivery process then there are various complications not only for the provider but for the billers as well. As they have to prepare bills for the non-credentialed physician under locum tenens arrangements. This is why billers must work closely with the provider and credentialing team to make sure that only the contracted physicians have provided the medical treatment.