Great news — your healthcare organization (or the community you serve) has grown enough to bring in one or more critically needed clinicians. But now comes the harder question: how long will it take for your busy staff to get these new providers enrolled and credentialed so they can begin seeing patients and be reimbursed for their services? The process involves a long list of detailed, time-sensitive steps that can take months without the right expertise and tools in place.
Advantum Health has over 30 years of experience in partnering with providers and payers to significantly cut down the amount of time and effort needed to make these essential steps fast and accurate. Advantum Health helps ensure that applications are completed and submitted successfully and accepted the first time.
“Our Provider Enrollment Services — what we call PES for short — serve 25,000 providers and continue to expand and evolve over many years,” said Sarah Wilson, Advantum Health’s Director of Provider Enrollment. “Currently, we have more than 4,000 provider organizations that count on these essential steps to get it right the first time and guide them through what other providers can find to be a slow, arduous process.”
What’s Credentialing and Why It Matters
Medical credentialing is the process of verifying a healthcare provider’s credentials — including education, training, licenses and experience — to help ensure they meet the standards required by insurance networks and regulatory bodies. It’s a critical step for empowering providers to deliver care and receive optimal reimbursement.
Credentialing and enrollment involve determining and verifying a long list of documentation, such as:
- Personal information, such as email address, street address, phone number
- Medicaid number
- Medicare number
- Copy of National Provider Identifier (NPI) number documentation and confirmation letter.
- Unique Physician Identification Number (UPIN number)
- Federal tax ID number
- Copy of current federal DEA and current state-controlled substance registrations or certificate(s)
- Copy of current driver’s license or passport
- Permanent resident card, green card or visa status (if applicable) All non-U.S. citizens must provide a copy of their green card
- Copy of medical school diploma and training certificate(s), internship, residency and fellowship certificates
- Current continuing medical education, including CME activity for the past three years
- Copy of current board certificate, including the name of issuing board and dates of board certification/recertification
- Copy of all current active state license wallet card(s) and wall certificate with expiration date and number
- Current Curriculum Vitae with complete professional history in chronological order, with no gaps (months and years must be included)
- Current hospital and facility affiliations
- Completed Delineation of Privileges Form
- Work history including all practice locations and employment affiliations
- Any disciplinary actions, including explanations
- Malpractice claims history with details.
- Certificate of Professional Liability Insurance Coverage or declaration page (face sheet) of policy, if applicable.
- Third-party documentation (such as court documents, dismissals) for all malpractice/disciplinary actions or completion of appropriate explanation form, if applicable.
- Three written letters of recommendation from providers who directly observed the provider in practice within the past year. (Professionals submitting these recommendation letters must assess the provider’s clinical competence and specify the date they last observed him or her in practice, by month and year)
- Military discharge record — Form DD-214 (if applicable)
- Copies of current immunization records and most recent TB test results (if available)
- Case log from the last 24 months (if applicable)
- Mammo numbers and Mammography Quality Standards Act (MQSA)if applicable
- Copy of National Board of Medical Examiners (NBME), Flexible Surgical Set Embedding (FLEX), U.S. Medical Licensing Examination (USMLE), or Special Purpose Exam (SPEX) scores.
- Copy of any of the following: BLS, ACLS, ATLS, PALS, APLS or NRP certificates
- Completed Locum Tenens Practice Experience Form (if applicable)
- For foreign graduates: ECFMG certificate number and Fifth Pathway documentation
“These requirements continue to evolve, so as you can imagine, this requires a great deal of information gathering and validation before applications can be submitted, both to payers and provider organizations,” Wilson noted. “A single error or omission can reject a clean submission or recertification, causing even more time spent on resubmission, a risk of non-compliance to providers and provider organizations, and a delay in reimbursements essential for continued operations.”
The Clock (or Calendar) Is Ticking
Best-case scenario, enrollment and credentialing take 60 to 180 days — roughly two to four months — before providers such as physicians, physician assistants, nurse practitioners and others can begin delivering care.
The credentialing process with a payer can take several months even with a clean application that meets all documentation requirements. Depending on a clinician’s contract with a provider organization, they may begin receiving pay, even if they are not yet able to see patients or bill for services.
How to Streamline the Process
Centralize data. Use a single source of truth for provider documents, such as Advantum EVE™, a proprietary web-based platform that uses completed provider profiles to deliver a single comprehensive file accessible by multiple users. This helps ensure tasks are completed accurately and efficiently. EVE also provides:
- Automated alerts for expiring licenses and re-credentialing deadlines
- Standardization of workflows across facilities and payers
- Customized reporting
To recap, Advantum streamlines provider credentialing by leveraging two main assets: an experienced team of experts and the artificial intelligence-powered Advantum Ai™ and Advantum EVE tech suite.
“Advantum’s Provider Enrollment Services encompass the perfect marriage of experienced, hands-on professionals with ever-evolving AI-based tools that help essential services like credentialing and enrollment move more quickly and accurately, with fewer delays and revenue risks. This enables clinicians to focus on care, not paperwork or avoidable revenue delays,” Wilson noted.
How to Get Started
Medical credentialing services simplify enrollment and insurance credentialing, helping reduce denials and boost reimbursements. For more information on Advantum Health’s provider enrollment and other revenue cycle management services, reach out and book a demo today.