Professional Credential Services is an essential step in the medical sales cycle, enabling doctors to receive paid reimbursements for medical services rendered and patients to have more access to their insurance plans for the treatment they receive from physicians. The process is a complex one but can be simplified into three basic steps. First, we need to identify qualified physicians. Next, we need to find qualified patients. And finally, we need to obtain the insurance policyholder’s contact information to complete the doctor-patient interface.
It goes without saying that the physicians and the patients we refer to must be qualified and authorized to receive medical care. This is the main reason why physician credentialing services are important. In some countries, especially those that practice private healthcare, there is a legal requirement that licensed healthcare professionals engage in this process and comply with specific physician quality indicators.
When a physician follows all the necessary measures and complies with the CAQH criteria, he or she will become eligible for provider enrollment. This is the next important step in physician credentialing services. Once a potential provider is enrolled, he or she will have the opportunity to apply for a preferred provider organization (PPO) and reimbursement program.
One of the benefits of physician credentialing services is that they reduce the risk of fraud and waste by removing fake or inaccurate data. For instance, if physicians have admitted to patients that they are not licensed to do a particular procedure, the resulting claims would most likely be fraudulent. By removing false or inaccurate data, these programs improve the quality of care because providers are better informed about what patients actually need. This leads to happier patients and lower claims, both of which are important to payers.
There are many other benefits of physician credentialing services that are particularly relevant to patients. First, they provide immediate access to licensed physicians. By eliminating the hassle of searching for a new doctor, the patient can go to the CAQH website and apply. Even if the site does not require an application, it will help expedite the process by making it significantly easier. Many Medicare and Medicaid enrollees who switch providers are initially denied due to provider non-compliance.
Second, once a patient has been accepted into a preferred provider organization, he or she will be able to see any physician of his or her choice. Previously, there was a tiered system where physicians had to choose between themselves and their patients. However, with physician credentialing services, the quality of care will be as high as it can be regardless of whether one physician signed up. Providers will have to choose whether or not they want to participate in the preferred provider program, but they will have no impact on what patients can see if they switch.
The third benefit is that if a physician decides not to participate in a credentialing service, he or she will still be able to practice medicine. Currently, many hospitals, nursing homes, and short-term care facilities are struggling with overcrowding and understaffing. By partnering with a CAQH provider, these facilities will access physicians who accept their credentialing services. Without this provider network, these facilities would not meet their obligations to patients by providing quality care.
By no means is physician credentialing services a perfect system. However, the benefits to insurers, patients, providers, and institutions overall make this system worthwhile. While some insurers continue to avoid these types of programs, others have embraced them wholeheartedly and expect to pay their premiums and meet their claims annually without any issues.