Physician and Medical Professionals Credentialing Services Overview

Credentialing is the process by which insurance networks, healthcare organizations and hospitals obtain and evaluate documentation regarding a medical provider’s education, training, work history, licensure, regulatory compliance record and malpractice history before allowing that provider to participate in a network or treat patients at a hospital or medical facility. Patients come to a doctor with a private and government insurance plans, such as Medicare and Medicaid, that covers part or all of their medical visits, procedures, prescriptions and hospitalization costs. If a doctor is not “credentialed” or contracted by the patient’s insurance company, Medicare, or Medicaid plans, they may not be paid for their services and cannot submit their medical bills.

Amazingly enough, when working with many practices we discovered that most medical offices were utilizing their top staff to file credentialing and recredentialing forms. Even some of the most successful practices were using their best personnel to deal with this mundane, tedious, time-consuming task.

In fact, these offices were using their best staff not to deal with the actual insurance carrier; they were dealing with a company to which the carrier has outsourced their credentialing process. There are companies have been servicing the insurance carriers for many years and at the same time wasting the valuable time of some of your best staff members.

Professional Healthcare Management can handle all of your credentialing and recredentialing and contracting needs, including hospital privileging. We deal with all aspects of credentialing, including CAQH initial applications and reattestments, contract procurement and negotiations with insurance carriers and hospital applications for appointments and re-appointments. By outsourcing your credentialing process you will free up your staff to focus on holding those same insurance companies to the contracts they have signed. We continually track your applications with carriers to ensure that your credentialing application is getting the attention it deserves.

In addition, we provide all of your plan preview needs.  Professional Healthcare Management will work with insurance companies/networks regarding fee schedules and advise when necessary of changes you need to make to optimize your reimbursement potential. We have many years of experience in knowing what information is essential for you to know about reimbursement. There is more to insurance contracts than fee schedules. We will get the answers that you need to make an informed business decision before signing an insurance contract.