Credentialing for nurse practitioners (NPs) is a complex and time-consuming process with steps ranging from completing lengthy applications to gathering supporting documentation. It can be tedious to follow the requirements of each individual payer to ensure your application is processed smoothly and efficiently. While issues may arise during NP credentialing, with a little preparation, you can proactively overcome them.
What is Nurse Practitioner Credentialing and Why is it Important?
To be to be eligible to bill government agencies and healthcare insurance companies, NPs must be credentialed. Nurse practitioner credentialing is the process used to evaluate and qualify nurse practitioners. The credentialing process involves the verification of education, licensure, certification, and reference checks.
Through this credentialing process, NPs verify their adherence to Centers for Medicare Services’ (CMS) national standards of care and demonstrate their professional knowledge, skills, and decision-making for compliant practice. Ultimately, the credentialing process provides verification to payers of your qualifications to provide high-quality healthcare.
Common Credentialing Issues for Nurse Practitioners
The credentialing process for advanced practice registered nurses (APRNs) can be complex, and issues may arise, particularly with health plans. It often is a “hurry-up and wait” process as many steps are controlled by the payers and cannot be rushed. During this time, you may want to focus on developing policies and procedures to align your practice for renewals and re-credentialing down the road.
Credentialing by health plans varies widely. If you wish to operate as an independent provider and accept insurance, it helps to choose an area that is less saturated with providers to increase your payer contract options. It is a good idea to have back-up payers in mind in case any of your desired payers are not accepting new providers in the area or not accepting NPs at all. To learn more about designated shortage areas, go to hrsa.gov.
Another common issue is cost. At the beginning of the credentialing process, you will need to provide a practice address, proof of malpractice insurance, and state oversight (if your state requires it). That means you will be incurring costs, including rent (unless you are operating out of your home address), while you wait to become credentialed. Often, we recommend NP entrepreneurs maintain some level of employment during the credentialing process to offset these costs.
Overcoming Nurse Practitioner Credentialing Issues
Credentialing is a complex and lengthy process. However, you can limit the headache by taking the time to meticulously plan for and carefully execute the following steps:
- Pre-application. Before submitting any payer applications, obtain and validate all licenses, certifications, and practice information. Once that data is verified and confirmed, you can begin determining which payers you would like to contract with.
- Submission. Once the required information is collected and a payer list has been established, payer applications can be submitted. In most cases, the first submission should be to Medicare since some commercial payers require a Medicare Group Number prior to applying.
- Review. If approved, it is important to closely review each contract, including the fee schedule because there may be terms within a contract that restrict your cash pay fee schedule. Contract violations may cause serious repercussions, so it is critical to have a full understanding of all provisions before signing. It also is advisable to seek legal counsel before signing any legal agreement related to your practice.
- Return: After careful review, the contract can be executed and returned. The payer will then provide an effective date for you to begin seeing patients.
If you feel overwhelmed by the process, or just want support, a professional credentialing and enrollment consultant can help.
Lean on Credentialing Experts to Ease the Burden
Credentialing can be an arduous process. To help you stay on track, NP Advantage’s experienced professionals, who understand both state and insurance regulations, can help guide you through this journey. We’ll help you manage every step of the process so that you can avoid nurse practitioner credentialing issues that take time away from focusing on quality patient care. Let us know how we can help.