The cost of credentialing with insurance companies varies drastically between the different modes of obtaining credentialing. The process your healthcare organization undertakes to credential a new healthcare provider is the primary factor which determines the cost. Time and the hourly rate of the people in charge of managing the credentialing process will affect the total amount. Here is a quick breakdown of what to expect:
- Provider’s doing it themselves: $1600- $2000 (assuming hourly rate =$100 p/h)
- In-house credentialing team: $320-$400 (assuming hourly rate =$20 p/h)
- CVOs: $200-$300
These costs are indicative of the time and hourly rates of people working on the process. In addition, there’s the application fees for institutional providers that needs to be paid to the payor to become an in-network provider for initial enrollment.
For a more detailed breakdown of credentialing costs, please continue reading.
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What is Medical Credentialing and Recredentialing?
Both medical credentialing and recredentialing are vital aspects of the provider enrollment process, helping to establish and maintain the credibility and reliability of healthcare professionals within the insurance network.
Medical credentialing is a meticulous and in-depth evaluation process that healthcare providers undergo to ensure they meet the stringent standards set by insurance companies like Medicare, Aetna, United Health, etc. This procedure involves a comprehensive review of a provider’s qualifications, professional background, education, licensure, certifications, and other relevant credentials. The aim is to guarantee that healthcare professionals are competent, qualified, and in good standing within their field.
For example, a physician seeking to join Aetna will submit detailed documentation of their medical education, training, licensing, board certifications, and work history etc. and once approved, the provider will become an ‘in-network’ provider and would be able to claim reimbursements for services rendered to patients.
Recredentialing is an ongoing process that ensures healthcare providers maintain their credentials and stay compliant with the requirements of insurance companies. It involves regular updates and verification of a provider’s information to confirm that they continue to meet the established standards. This process typically occurs at regular intervals, such as every two years, depending on the policies of the insurance company.
For instance, a healthcare provider who has been part of an insurance network must undergo recredentialing to provide updated information on their licenses, certifications, and any changes in their healthcare organization.
Steps Within the Credentialing Process
The payor credentialing process is a multifaceted journey involving several crucial steps. From the collection of primary source data to the verification of qualifications and the meticulous submission of credentialing applications to insurance panels, each step is geared toward ensuring providers are credentialed accurately.
Here is a quick overview of what to expect with regard to credentialing duration:
|Commercial Carriers Credentialing
|60 to 90 days
|Average 45-90 days
|State credentialing (Medicaid/ MCO's)
|3 hours (Online application)
- Collection of Primary Source Data: Gather essential information directly from the primary sources, such as educational institutions, licensing boards, and previous employers. This step can take a few weeks as it depends on the responsiveness of primary sources.
- Verification of Qualifications: Thoroughly verify the provider’s qualifications, including education, training, licensure, certifications, and work history. Verification may take several weeks, as it involves coordinating with various entities.
- Credentialing Application Submission: Prepare and submit credentialing applications to the desired insurance panels or payors. The application submission process may take a few weeks, depending on the efficiency of the submission process and the specific requirements of each payor.
- Application Review: The insurance companies review the submitted applications, ensuring all necessary information is provided and accurate. The review process can take several weeks, during which the insurance company assesses the completeness and accuracy of the application.
- Credentialing Committee Review: Some insurance companies have credentialing committees that assess and make decisions on provider credentialing. The committee review process may take a few weeks to a couple of months, depending on the frequency of committee meetings.
- Contracting: Once approved, providers may enter into contracts with the insurance companies. Contracting timelines vary but can take several weeks, depending on negotiations and administrative processes.
- Notification of Credentialing Status: Providers are informed of their credentialing status, whether approved, denied, or pending additional information. Notification may occur within a few weeks to a few months, depending on the overall efficiency of the credentialing process.
It’s important to note that the timelines provided are general estimates and can vary based on factors such as the complexity of the provider’s background, the responsiveness of primary sources, and the specific policies of each insurance company.
What Information Is Needed to Get Credentialed?
Credentialing involves a thorough examination of a healthcare provider’s qualifications, credentials, and professional background to ensure they comply with regulatory bodies, healthcare organizations, and insurance companies. While there may be variations in summary, credentialing requires a range of information to ensure healthcare providers meet industry standards and regulations.
This includes obtaining the National Provider Identifier (NPI), maintaining an up-to-date CAQH profile, providing practice or healthcare organization details, and possessing a valid medical license. Additionally, credentialing involves verifying DEA licenses for controlled substance prescriptions, conducting primary source verification for medical licenses, reviewing license history, and submitting insurance information. Educational background, board certification, detailed work history, professional references, malpractice claims history, and malpractice insurance coverage are also essential components.
Finally, credentialing may necessitate providing insurance login details for platforms like Medicaid, Medicare (PECOS), and Availity to complete the process efficiently.
For more information regarding credentialing information, read our comprehensive credentialing checklist article.
What Are the Benefits of Using a CVO?
Incorporating a Credentialing Verification Organization (CVO) into your healthcare practice brings forth a multitude of advantages, streamlining complex processes and ensuring a robust credentialing framework.
- Expertise in Credentialing Processes
Credentialing Verification Organizations (CVOs) specialize in the intricate procedures involved in credentialing. Their experienced staff is well-versed in the nuances of collecting, verifying, and maintaining the necessary provider information, ensuring a thorough and accurate credentialing process.
- Time Efficiency
Utilizing a CVO significantly reduces the time required for both initial credentialing and recredentialing. CVOs have established workflows and efficient systems in place, expediting the entire process. This time savings allows healthcare providers to allocate more time to patient care, enhancing overall service delivery.
- Cost Efficiency
Utilizing a CVO often proves cost-effective for healthcare organizations. By outsourcing credentialing tasks, organizations can reduce overhead costs associated with in-house credentialing staff, ensuring optimal resource allocation. As illustrated in the beginning of this article, the opportunity cost associated with providers doing it themselves and also the costs of the in-house teams doing it, is substantially higher than outsourcing to a CVO.
- Compliance Assurance
Staying compliant with constantly evolving healthcare regulations and standards is a challenging task. CVOs dedicate resources to stay informed about changes in the regulatory landscape, guaranteeing that healthcare providers adhere to the latest requirements during the credentialing process. This proactive approach mitigates compliance risks.
- Reduced Administrative Burden
Outsourcing credentialing tasks to a CVO lifts a significant administrative burden from the shoulders of healthcare organizations. CVOs handle the complexities of data collection, verification, and documentation, allowing in-house staff to concentrate on core responsibilities without being overwhelmed by the meticulous details of the credentialing process.
- Improved Accuracy
CVOs prioritize accuracy throughout the credentialing journey. Their rigorous verification processes and attention to detail minimize the risk of errors. This commitment to precision ensures that healthcare providers are credentialed accurately, contributing to a more reliable and error-free credentialing outcome.
What Is the Cost of Credentialing With Insurance Companies Using a CVO?
The expenses associated with medical credentialing differ based on the medical specialty, the healthcare facility, and the credentialing verification organization (CVO) selected. Commonly, application fees ranging from $200 to $300 are standard. In many cases, healthcare facilities may provide reimbursements or partial reimbursements once the credentialing process is successfully completed.
Neolytix offers various credentialing options to suit the needs of the individual healthcare organization. Here’s a quick glance at the credentialing options:
- Pay Per Use
We handle new applications, demographic changes, portal verification, and ensure the upkeep of CAQH and PECOS. This efficient and comprehensive solution is designed for simplicity, priced per transaction with a minimum commitment of $1,000.
- Dedicated Team
For larger organizations like clinics and hospitals, we offer a dedicated team exclusively committed to your Provider Onboarding, Primary Source Verification, Credentialing, Enrollment, and Maintenance needs. This solution allows you to choose a customized scope that aligns with your specific requirements. With a commitment of at least 1 full-time equivalent (FTE), ensure a dedicated and efficient approach to your credentialing processes.
- Analytics and Automation
Elevate your credentialing capabilities with Neolytix CVO’s Analytics & Automation capabilities. This option adds a layer of sophistication to your credentialing processes, offering custom reporting through advanced visualization tailored for Management Dashboards using Power BI & and Dataverse.
The cost of credentialing with insurance companies can vary depending on several factors, including the type of credentialing service utilized, the extent of primary source verifications required, and the complexity of the credentialing process involved.
While basic database searches may incur lower costs, comprehensive credentialing services, including primary source verifications and support staff assistance, may require additional investment. Depending on the type of healthcare provider and the services offered, credentialing costs can vary significantly.
However, investing in thorough credentialing processes is crucial for ensuring compliance with insurance panel requirements, maximizing reimbursement opportunities, and minimizing the risk of claim denials.
While the medical credentialing process may require both time and money, the expertise of credentialing specialists can streamline the process and alleviate administrative burdens, ultimately contributing to improved medical billing processes and revenue cycle management for healthcare organizations.
Schedule a free demo to learn more about how Neolytix can ensure disruption-free operations at your healthcare organization.