Adding a new physician, or want to contract with a new insurance?

Credentialing a new physician within a practice is an important process to ensure the physician is qualified to provide care and can be reimbursed by insurance companies. Credentialing involves verifying the physician's education, training, experience, and licensure. Here is a step-by-step guide on how to credential a new physician within a practice, or contract with an insurance that is new to the practice:

Gather Necessary Information: Begin by collecting all necessary documentation from the new physician. This typically includes:
Medical school diploma Residency and fellowship certificates, if applicable State medical licenses Board certification DEA (Drug Enforcement Administration) certificate
Work history
Malpractice insurance and claims history
NPI
Basic Life Support (BLS) and Advanced Cardiovascular Life Support (ACLS) certifications, if applicable

Complete Application for Credentialing: Most hospitals, health systems, and insurance networks have specific credentialing applications. Obtain the appropriate forms from each entity with which the physician needs to be credentialed. The new physician must complete these applications accurately and thoroughly.

Primary Source Verification: Verify all of the information provided using primary sources. This means confirming the validity of medical licenses directly with the state's medical board and effective dates, verifying board certifications with the American Board of Medical Specialties (ABMS) or other relevant boards, and so on. This step is crucial and requires attention to detail.

Background Check: Conduct a comprehensive background check including criminal history, sanctions, and exclusion checks through databases like the National Practitioner Data Bank (NPDB) and the Office of Inspector General’s (OIG) List of Excluded Individuals/Entities. Privileging: Privileging involves determining and approving the specific procedures and services a physician is allowed to perform within the practice or hospital. This is usually based on the physician's training, experience, and competency.

Submit to Insurance Providers: Once the internal credentialing process is complete, the next step is to get the new physician credentialed with insurance providers, including Medicare and Medicaid. This involves submitting the credentialing application and supporting documentation to each insurer for verification and approval. This step is crucial for the physician to receive payment for services rendered.

Ongoing Monitoring and Re-credentialing: Credentialing isn't a one-time process. Practices must monitor the credential status of their physicians and re-credential them according to the policies of the hospital, health system, or insurance providers. This typically occurs every two to three years.

Keep Detailed Records: Maintain meticulous records of all the credentialing documents and correspondence. Keeping a well-organized file for each physician is essential for future reference and re-credentialing.

Communicate: Throughout the credentialing process, keep open lines of communication with the new physician, administrative staff, and any entities involved in the credentialing process. Updates on the status and any requirements for additional information should be communicated promptly.
Credentialing is a detailed and sometimes lengthy process that can take anywhere from a few weeks to several months, depending on various factors like the responsiveness of primary sources and the specific requirements of insurance providers. Starting the process as early as possible and staying organized are key to ensuring a smooth and efficient credentialing process for new physicians.