Background & Motivation
Can you explain what medical credentialing is?
“Credentialing is the process of verifying providers have all of the necessary training and authority to treat patients within a specified scope of practice. It is necessary for every provider, regardless of the type, and includes every step of the process from graduation from school to licensure to contracting with insurance companies. In practical terms however, the term “credentialing” is usually used to signify the process of providers becoming contracted for reimbursement for seeing patients from insurance companies.”
Can you give us five reasons why practices need credentialing and why it’s so important?
“Really, you only need one reason, and that is credentialing is how you get paid. It is how you as a provider create relationships with insurance companies, develop larger and broader patient panels, and ultimately get reimbursed from payers for the services you render.”
…credentialing is how you get paid.
Alexander Ralys, DO
“To answer the question fully however, I would say the next four reasons to get credentialed are as follows: to reassure your patients you are providing quality care, to determine your scope of practice and therefore liabilities, to develop relationships with payers and fellow colleagues, and finally to assure compliance professionally.”
Interest in Credentialing
How did you get involved with this process?
“I get this question a lot, and I think its one of those things that is just perfect happenstance. I was working with a colleague of mine as part of a large medical practice located here in Jacksonville, and we received a letter from Medicaid stating we had to complete some updates to our contract. We searched all around the area and found someone who was willing to take on the project. We ended up paying this consultant a significant amount of money to help us and they never finished the job. Eventually, the day of the deadline for us to get our group compliant came around, and I made a phone call to Medicaid myself and I was able to get the situation resolved in a few hours.”
“From that point I sat down with my business partner and we thought, “there must be a better way.” That same month we set out to create a consulting firm that could help providers in the same situation. Our goal was to use the resources we already had at our disposal to affordably help providers get their credentialing needs resolved. North Florida Credentialing was born out of this need and has continued to grow ever since.”
What is the biggest challenge you’ve faced in credentialing?
“The biggest challenge is a reoccurring challenge, and one that is experienced too often by providers. That challenge is getting in contact with someone at the insurance companies who is willing to discuss your problem and help you solve it. I firmly believe the credentialing process is unnecessarily complicated and a labyrinthine process that seems like an endless tunnel of red tape sometimes. Getting in contact with someone at insurance companies willing to help can be a significant challenge.”
How did you overcome this challenge or what did you learn?
“Unfortunately, this challenge will never go away I believe. Most of the major payers out there don’t feel any sense of urgency to add more providers to their networks and so they will always foster a system that gives them the upper hand in whether they choose to work with you or not. I have only been able to overcome this challenge by compiling lists of provider representatives and contact information that I can always pull from to get a hold of a helpful person.”
To be honest credentialing sounds quite boring. Do you find your work rewarding?
“Absolutely I do. There are aspects of credentialing that are mundane of course, just like any job. However, the reward of seeing young or new providers grow their businesses and being a part of that process always gives me that feeling of accomplishment. On top of that, it has been a great tool to develop new relationships and meet colleagues.”
Insight & Takeaways
We talked about a lot of things. What do you hope people will remember?
“I want providers to know that there are people out there who genuinely want to see them succeed. At North Florida Credentialing, we are those people. We are an inclusive, welcoming, and dedicated team who strives to provide affordable solutions to common problems faced by new practices. If you have questions, we are here to help, you can always call us.”