Med Management Quarterly

February 2008

What is Credentialing?

Have you ever wondered why credentialing can be so complicated? If so, you are definitely not alone.  For physicians and office administrators, credentialing is a necessary evil in order to participate with managed care plans. How and when it is done can be the difference between insurance claims payments or denials.

Managed care organizations such as health maintenance organizations (HMOs) and preferred provider organizations (PPOs) must successfully select and retain health care providers who will provide quality services to their subscribers.  This process of selection and retention is known as credentialing.  Credentialing is the process of review and verification of the information of a health care provider who is interested in participating with the various insurance carriers.  The fundamental purpose of credentialing is to ensure that the applicants meet the minimum requirements for a requested status and to determine whether the applicants' credentials are appropriate for the requested privileges with the insurance carrier.

Credentialing Specialist, Machelle Giordon, gathers detailed information on providers, such as education, malpractice coverage, and board certification.  With the advent of the National Committee for Quality Assurance (NCQA) and their accreditation of managed care organizations, managed care credentialing standards were established and the requirements for demonstrating competence were intensified.  As a result, the addition of more paperwork and demands on office staff resources has created a burden for physicians who participate in multiple managed care organizations.

Why is it critical?

•  Most insurance companies will not notify the provider if information is incorrect or missing.
•  OSCG meticulously monitors the providers status with each insurance company.
• Most office staff does not have the time to check if their providers were linked correctly.
• Steer clear of frustration and distraction.  OSCG can keep your physicians and administrators happy.  Your payments won't be stalled because of credentialing issues and cash flow will stay positive.

 O'Sullivan Consulting Group can assist providers in dealing with some of the additional demands of managed care plans and credentialing.  For further assistance please contact Machelle at 330-723-2111 or machelle@osullivanconsult.com