How the Credentialing Process Works

Who doesn’t love a good sport’s reference in an article? Since the NBA and NHL have recently ended and the MLB is in full swing, I feel it only appropriate to use baseball to analogize the credentialing process.

So let’s play ball.

The important roles of the pitcher and catcher in baseball is a good illustration to describe the tedious workings of the credentialing process between the provider’s office and insurance company.

Credentialing Staff

Pitchers– Admin staff at provider’s office

Gathers provider documents and sends it off to the catchers

Catchers– Admin staff at an insurance company

Accepts providers documents from the pitchers for processing

The “catchers” or insurance companies may “signal for another pitch” by going back to the “pitchers” for additional and/or missing items. If this happens, the already lengthy credentialing processing time (30 – 180 days from the time all the completed paperwork has been received) could create the dreaded “rain delay.”

For example, Dr. Smith completed her application and submitted it to Insurance Company A on 12/10/2014. On 1/10/15, Insurance Company A contacts the provider with a request for a W9 and a copy of her liability insurance. Dr. Smith was so busy she didn’t notice that Insurance Company A asked for these two items on the application. Dr. Smith gathers these documents, but doesn’t fax them to Insurance Company A until 2/10/15. February 10, 2015 is when the clock starts ticking and Insurance Company A could have Dr. Smith application finished anytime between March 10, 2015 to August 10, 2015 (180 days). So from 12/10/14 (when she began working) until potentially August 10, 2015 Dr. Smith is considered out-of-network with Insurance Company A, therefore claim’s rejections are possible if Dr. Smith is seeing clients during those eight months.

The above example illustrates how important it is for the pitchers to send accurate and complete documentation to the catchers, as well as making sure the catchers are on top of their game by tenacious fielding of calls and emails, keeping up with the provider’s credentialing status.
Despite the pitchers tenacity, however, some of your behemoth insurance companies on average process near that 180 day mark.

I hope this article helps to explain the credentialing process and timelines. Submitting accurate paperwork timely and follow-ups are key. Many payors will give a provider three chances (strikes) to submit additional info if necessary. You do not want this to happen, if you strike out they will require you to start the process all over again. So get your paperwork in on time, don’t strike out and once you are paneled it is a homerun!