What is Medical Credentialing?

Ensuring a healthcare provider has the proper education, training, certification and credentials not only makes certain that they are qualified to provide care, but it is also integral to being “in-network” with health insurance companies.

Credentialing makes this happen. But what is it and how, exactly, does it work? Here are the details:

Credentialing—The Basics

What is Medical Credentialing?

At its core, credentialing assesses the qualifications of a physician and determines whether or not they are qualified to treat patients. People expect their doctors to be competent, whether they’re seen by them at a doctor’s office or in an operating room, and credentialing ensures that this is true.

The Credentialing Process

The credentialing process involves the collection and evaluation of data on physicians, such as their resume, educational transcripts, work experience, license verifications and more. Credentialing also identifies anyone with disciplinary actions or sanctions against them or any criminal history, and it verifies the accuracy of the documents submitted to the hospital or insurance company. The entire process takes about 60-180 days.

Why Physicians Should Be Credentialed

By proving their qualifications, physicians can then become “in-network.” That is, a physician will be contracted with a health insurance company to provide their services to members for a pre-negotiated price. Being credentialed with the health insurance companies in a physician’s specific geographic location is crucial, as then they will be able to provide care to a much wider number of potential patients. Additionally, by being out-of-network, a physician won’t be paid by the health insurance company, leading to out-of-pocket expenses for the patient.

Credentialing, then, is the first and foremost part to getting “in-network.” To get started, check out Medical Revenue Associate Inc.’s credentialing services, or give us a call at 215-497-1001 today to learn more!

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