New to Provider Credentialing? Top Questions & Tips to Make It Easier

Provider credentialing

Are you new to the world of provider credentialing? Or are you looking for ways to make your credentialing processes more efficient and less time-consuming? Look no further.  

Below, I answer some of the top questions asked by credentialing and payer enrollment professionals at health systems and health plans. 

Should an organization wait until the provider has completed credentialing and is approved by the credentialing committee before enrolling them with health plans? 

The approach to enrolling providers with health plans can vary based on whether the payer agreements are delegated or non-delegated.  

If you have a delegated credentialing agreement with a payer, you must wait until the provider has been approved by your credentialing committee. This is because you cannot submit a provider without a credentialing committee (CRED) date from your organization.  

For non-delegated payers, there is more flexibility. Some organizations prefer to wait until the provider has gone through the credentialing committee and received their CRED date before submitting to non-delegated payers.  

This can reduce the likelihood of payers requesting additional information that might have been missing if the provider was not yet fully verified and credentialed by your organization. 

What is a new or upcoming trend in credentialing that you see?  

We are seeing the integration of credentialing and enrollment software with various registries and portals, such as the National Provider Identifier (NPI) Registry and payer portals.  

This integration enables automated verification of provider credentials and streamlines the enrollment process with various insurers, reducing manual errors and time delays.  

Another trend is self-service portals to boost user experience. Providers want a fast and effortless way to complete their application. Self-service portals enable providers to upload and update their credentialing information, track their application status, and receive notifications about required actions or expiring credentials.

And, of course, we can’t forget about Artificial Intelligence (AI), often referred to as ‘hype with hope.’ AI can help expedite the provider verification and enrollment process. More specifically, it can help automate the process of enrolling providers with payers and validating information quickly, thereby enhancing the efficiency and accuracy of credentialing tasks.  

Additionally, AI and machine learning algorithms can analyze vast amounts of data to identify patterns and predict potential issues in credentialing applications. For example, AI can flag inconsistencies or missing information in real-time, allowing for quicker resolutions. 

What are some of your top resources to help me do my job better and grow in this field? 

The National Association Medical Staff Services (NAMSS) has multiple resources available, including Credentialing 101 courses, that are beneficial for anyone new to the field or for those who want to enhance their knowledge.  

Find mentors and connect with others in the credentialing field, as they can be great resources to learn from and collaborate with. 

Finally, attend conferences and get to know others so you can build a network. Conferences like NAMSS provide an opportunity to meet knowledgeable people who can help you advance in your career.

Are there any tips or tricks to make jobs or processes more efficient and less time-consuming?  

  • Maintain a list of all your tasks to keep track of what needs to be done. 
  • Break down tasks day by day to avoid feeling overwhelmed. Focus on daily progress rather than the entire workload. 
  • Prioritize tasks based on provider start dates and due dates with payers to ensure timely completion. 
  • Combine provider start dates with accounts receivable (AR) hold statuses to avoid delays in claim filing. Ensure timely submission to release claims efficiently. 
  • Be flexible and willing to adjust your processes as needed to improve efficiency and effectiveness.  

Want to know my best piece of advice for new and seasoned credentialing professionals? Stay organized, use software to track provider details, and prioritize tasks effectively. By doing so, you will improve your organization's overall efficiency and bottom line. 

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