Enrollment & Credentialing

Generally speaking, health insurers only treat as contracted those physicians who have both signed a contract and been enrolled and credentialed. Similarly, Medicare and other public payers will generally only pay physicians who are formally enrolled. Finally, hospitals and other health facilities usually allow only those physicians who have been fully credentialed and privileged to admit patients to or provide services in those facilities.

These enrollment, credentialing and privileging requirements can be particularly problematic for physicians who start working at a new medical practice before the enrollment, credentialing and privileging processes have been completed by the relevant health plans and health facilities. Indeed, depending on the medical group’s contract, an uncredentialed physician employee of that group may be treated as an out-of-network physician or even be prohibited from receiving any payment for services provided to the health insurer’s beneficiaries.

Credentialing issues are not limited to payment. A health insurer’s or hospital’s refusal to credential a physician for a failure to meet professional standards may be reportable to the National Practitioner Databank (NPDB) and to state licensing agencies.

For this reason, it is imperative that physicians and physician practices take the enrollment and credentialing process very seriously.

Most commercial health insurers follow the credentialing standards established by the National Committee for Quality Assurance (NCQA). These standards require initial and ongoing verification of all of the following:

• license to practice
• Drug Enforcement Administration (DEA) or Controlled Dangerous Substances (CDS) certification
• education and training
• work history
• professional liability claims settlement history
• sanctions, restrictions or limitations in scope of practice, as defined by the State Board of Medical Examiners or licensing agencies
• Medicare and Medicaid sanctions
• application with attestation

Because any misrepresentation is itself a potential basis for rejection, physicians need to ensure they handle all credentialing and re-credentialing applications carefully.

With the stakes so high, many physician practices use a credentialing service to maintain their information and manage the credentialing requests they receive. Indeed, the Council for Affordable Quality Healthcare (CAQH), which represents the nation’s leading health plans, networks and managed care industry trade associations, has developed the Universal Provider Datasource® (UCD). By completing and keeping updated one standardized online application, physicians can eliminate the need to complete multiple credentialing applications, free of charge.