New Physician Credentialing – Timing is Everything

It is always a good sign when your practice recruits a new physician fresh from medical school. It brings attention to your practice, and can help you build a reputation of being a forward-thinking practice that offers the newest and best patient care practices.  Don’t let the credentialing process undermine those immediate benefits. Credentialing for a new physician requires advance planning and a fairly long lead time.  As soon as you know the new physician will be joining your practice, you need to start the credentialing process. You want to make sure that as soon as s/he arrives at your door ready to begin seeing patients, they are also set up to bill properly.

BEWARE:

If you have to wait for your new physician to receive practice credentials, you cannot bill for his/her patient services in the meantime. Billing for your non-credentialed physician will result in denied claims to government health programs and either denials or out of network claims payment by commercial plans. Claims that are improperly paid during this time period can lead to audit problems, such as demand for reimbursement repayment, and a possible investigation into your billing practices. Most third party payers will not retroactively reimburse your practice for the new physician’s patient services, so that isn’t an option either.  If a patient receives care from a non-credentialed physician, the patient may have to self- pay.  As you can see, it’s important to get the new credentialing done right and on time, the first time!

Let’s do this the right way.  Here are the important details to consider when credentialing a new physician:

TIMING

1. In some states, new graduates must wait 60 days after the completion of their training before they can submit a credentialing application.
2. If the new graduate is relocating from out-of-state, s/he can submit the credentialing application 30 days before his/her start date.
3. Usually, there is a 60- to 90-day period between the receipt of a completed credentialing application and a new doctor being approved.
4. Application for an NPI- when submitted online, the number is usually received in 10 days, but always allow for a longer period of time.

COUNSEL YOUR NEW PHYSICIAN

Your new doctor should be careful when choosing his/her primary specialty because the primary specialty choice:

1. Determines whether the new graduate is designated as a primary care physician or specialist for managed care networks
2. May affect the way claims are processed and paid
3. Will be shown in online insurance directories

MAKE CREDENTIALING PART OF THE CONTRACT

You don’t want the new physician causing delays in the credentialing because of inattention. Make credentialing a priority by including it in the physician contract and other agreements. Detail what is expected of the new physician vis-à-vis credentialing. You have the leverage to say that if the new physician fails to meet the practice’s credentialing and privileging process then they cannot become part of the practice.

COLLECT THE MYRIAD DOCUMENTS

As part of the credentialing process, a new physician will need to provide:

1. A national provider identifier (NPI), obtained through the Centers for Medicare & Medicaid Services’ (CMS) National Plan and Provider Enumeration System. Credentialing requirements for each health plan
2. If you follow the National Committee for Quality Assurance (NCQA) guidelines, it requires that physicians have a license and malpractice coverage before applying for credentialing.
3. Privilege requirements for contracted hospitals
4. If the payer requires that the new physician carry clinical privileges at a hospital that is another application process with its own timeframe.

The physician may also need to submit:

1. Proof of education
2. Valid Drug Enforcement Administration certification
3. Proof of board certification

Credentialing is a detailed and sometimes laborious process. That’s what we do. We take care of the credentialing process. Whether you have a new physician, a transferring physician or need re-credentialing, call us. We can save you time, money, and frustration!