Physician Credentialing

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health-insuranceOverview

Credentialing is used to evaluate physicians for different purposes and is required of almost all physicians. It is utilized by hospitals when evaluating physicians for medical staff positions and hospital privileges and when enrolling in health insurance plans as a participating provider. Unfortunately, this process has not been streamlined and can be very time consuming and complex.

Provider credentialing is meant to verify experience, expertise, and willingness to provide medical care. It is often a complex, ongoing process that can take several months to be completed and approved and is an administrative hassle for employers, insurance companies, and physicians. While credentialing was historically just proof of licensure, modern credentialing goes far beyond proof of diploma and license.

Credentialing Requirements 

Hospital and medical practice credentialing often examines the professional training and experience of a physician and requires verification that the physician applicant:

  1. is who he/she claims to be;
  2. maintains a current license;
  3. carries adequate malpractice insurance; and
  4. meets the minimum requirements established by the medical practice or hospital bylaws.

(see Medical Staff Credentialing for more details.)

Insurers will evaluate a doctor’s education, training, residency, licenses and any specialty certifications. They assemble complete information about a physician’s background and qualifications by checking reliable sources, such as the National Practitioner Data Bank and the Georgia Composite Medical Board to confirm there are no limitations on the physician’s license. They will also review a physician’s malpractice claims history, a history of all hospital privilege, and confirm all aspects of relevant training.

Steps to Successful Credentialing

Credentialing needs to be completed as soon as possible. When a physician joins a medical practice or hospital, a physician will often need to complete the credentialing process for both the practice and the insurance companies the practice participates in. It is important for both the practice and the new physician to start this process as early as possible, as credentialing can take up to several weeks or months, especially with insurers. If a physician is negligent in providing necessary documentation, this can create a financial dilemma as they will not be able to bill for their services until they are properly credentialed with the insurer. Often, it is smart for a practice and new physician to establish a starting date that is tied to the successful completion and submission of all required documents.

Be thorough and detailed when completing the process. Missing, outdated, and incomplete information and documents will lead to a longer and more drawn out process. On all forms, such as the Coalition for Affordable Quality Healthcare (CAQH) form or the Georgia Uniform Healthcare Practitioner Credentialing Application Form (UHPCAF), complete all data entry boxes regardless of answer. Confirm all dates and data and avoid guessing or estimating. Maintain all data and forms, potentially in a spreadsheet, to help save time with credentialing for other organizations or re-credentialing which is often required on an annual or bi-annual basis.

Georgia 

The Georgia Uniform Healthcare Practitioner Credentialing Application Form (UHPCAF) and the Georgia Uniform Practitioner Healthcare Credentialing Reappointment Form was developed by the Georgia Hospital Association, the Georgia In-House Counsel Association, the Georgia Association Medical Staff Services, the Georgia Association of Health Plans and the Medical Association of Georgia. These standardized documents were created with the objective of standardizing credentialing forms for physicians. The applications can be downloaded on their website, but it is important to note that the UHPCAF is voluntary and there is no state requirement that a hospital or insurance company accept it.

The credentialing process can be complex, time consuming, and very frustrating for all parties involved. Physician’s and practices can face financial challenges if a new physician struggles to get credentialed by an insurer or acquire hospital privileges. An experienced attorney can help a physician or medical practice with this burdensome process.

Atlanta and Augusta Georgia Healthcare Attorneys and Litigators

If you have questions regarding this blog post, a credentialing issue or dispute, you may contact us at (404) 685-1662 (Atlanta office), (706) 722-7886 (Augusta office), or info@hamillittle.com.

*Disclaimer: Thoughts shared here do not constitute legal advice.

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