Proper Credentialing of Medical Staff is Absolutely Critical: Here’s the Best Way to Achieve It

A bill submitted by a physician without proper credentialing is considered the legal equivalent of a false bill and can lead to big trouble. Proper credentialing of your medical staff does not only ensure the quality of care but also protects your organization from going against any state or federal rules regarding how reimbursement requests are submitted. To know what to do to ensure your medical staff is properly credentialed to bill all payers, read along!

Proper credentialing of your medical staff is crucial. It’s not just to ensure that the best quality care is being delivered but also to guarantee your organization does not run afoul of any state or federal rules regarding how reimbursement requests are submitted.

If you don’t believe such an issue can be costly, an urgent care provider network in the Southeast just paid $22.5 million to the federal government to settle civil charges of using improperly credentialed doctors to bill for care. Between 2013 and 2018, this group of urgent care physicians did not obtain proper credentials to bill Medicare, Medicaid, and TRICARE for services. Instead, it simply linked billings to the doctors in its network that were properly credentialed.

When the U.S. Justice Department announced earlier this month that the medical group made that huge payment to settle a whistleblower lawsuit, it noted thus: “there is no evidence in this case that any provider lacked a medical license or that patient care was compromised due to the conduct at issue.” Credentialing was the only issue. A bill submitted by a physician without proper credentialing is considered the legal equivalent of a false bill. Obviously, that can lead to big trouble.

To ensure your medical staff is properly credentialed to bill all payers, your organization should perform the following tasks:

• Review your existing provider credentialing applications. All applications should contain basic but critical information for your medical staff, including copies of relevant licenses, board certifications, DEA registrations, sanctions, and malpractice claims. Some credential applications go further than that and require items such as a criminal background check, privilege history, and even reference letters from medical peers. Checking the applications on an ongoing basis (every six to 12 months) will ensure that documents don’t go out of date. You should also check with staff to see if their CME credits are up to date.
• For new applications that have just been submitted, obtain a tracking number from the payer. Set up a spreadsheet to ensure tracking and follow-up calls and emails are performed in a timely fashion.
• Peer references can go out of date (the referencing physician may retire or relocate). If a staff member needs a new peer reference, ensure that that individual is willing to vouch for the doctor in question. Their contact information for a peer reference letter should be not only current but also functional. In other words, if a peer gives an email contact or fax number, they should actually respond if they are sent correspondence.
• For a physician just entering your practice or network, check on their patient outcomes if such data is available. Given that your practice or network is likely involved with MACRA, ACOs, or other value-based initiatives, a physician with middling outcomes can impact reimbursement for the entire enterprise.

Credentialing is usually a routine, if not a mundane process. If staff treat it as a matter of rote, it can lead to oversights and problems that may surface months if not years later. Following the steps above is not only a way to avoid an unexpected disaster but also a way to ensure that your practice operates in an optimal fashion.

To obtain services regarding credentialing or the overall improvement of practice performance, please contact WCH Service Bureau’s Olga Khabinskay at olgak@wchsb.com.