Medical Vendor Reviews

What You Need To Know About Medical Credentialing

As a medical professional, medical credentialing is most likely a topic you hear of often. Medical Credentialing is a method used to assess the qualifications and practice history of a doctor. This systematic, in-depth, and time-consuming process also includes the process of becoming associated with insurance companies (also known as provider enrollment) so that you can accept third party reimbursement. Becoming associated with an insurance company allows you to become an in-network provider. With the cost of healthcare today, medical credentialing has become more important and more necessary than ever.

TOP 5 LARGEST HEALTH INSURANCE COMPANIES:

If you are considering becoming medically credentialed with an insurance company, below you will find the top 5 largest US Health Insurance Companies

  1. Wellpoint Inc.
  2. Cigna Health Insurance Company
  3. Aetna
  4. Humana
  5. United Healthcare

THE IMPORTANCE OF MEDICAL CREDENTIALING

Medical Credentialing has become more important as the scope of services covered by insurance plans has become broader. With the introduction of The Affordable Care Act, there are now less restrictions regarding pre-existing conditions. In fact, no insurance company is allowed to deny you coverage, charge you more, or refuse payment on essential health benefits surrounding pre-existing conditions. For this reason, patients are no longer seeking out specialists that are out of network.

CHALLENGES OF MEDICAL CREDENTIALING

As you begin the medical credentialing process, you may notice that insurance companies preferred provider networks, or insurance panels, are very full. This is making the process of becoming an in network provider more challenging with barriers to entry becoming more difficult to meet. Additionally, you may run across an insurance company saying their insurance panels are closed. However, this usually means that the insurance company is being highly selective on which providers they are allowing on their list, which results in more work on your end.

COMPANIES SHOULD TAKE CARE OF:

  • Verification of unrestricted state medical license with appropriate licensing agency
  • Verification of valid, unrestricted DEA certificate and CDS certificate, if required by the state
  • Board certification status with the American Board of Medical Specialties or the American Osteopathic Association
  • Verification of education and training
  • Review of work history
  • Verification of prior sanctioning activities by regulatory bodies and by CMS
  • Review of malpractice claims history
  • Verification of adequate malpractice insurance
  • Proof of appropriate professional licensing

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