What is Provider Recredentialing?
To provide premium patient care and maintain compliance, routine and ongoing provider screening and license verification is necessary. This periodic provider screening and verification process is known as recredentialing. The recredentialing process verifies the education and training of providers and notifies healthcare organizations of abuse or fraud.
Although routine provider screening and monitoring can be burdensome for hospital administration, neglecting to do so may cost hospitals millions in civil monetary penalties, delayed reimbursement, and litigation. To protect patients, providers, and healthcare institutions, healthcare organizations can leverage technology that continuously monitors primary sources and automatically notifies the organization of potential concerns keeping providers in full compliance.
How Often Does A Provider Need to Be Recredentialed?
In most states, providers must be credentialed upon hire and then recredentialed every two years. Some exceptions may apply, such as in the state of Illinois, where provider recredentialing is required every three years.
Health plans may also have additional requirements. Healthcare organizations should check applicable state laws and regulations as well as insurance requirements for time periods and provisions.
Verisys helps you provide quality care to your patients through access to critical data for full transparency on your providers, suppliers, and support individuals and entities.
What Is Needed to Begin the Recredentialing Process?
A provider should be notified at least 60 days prior to the recredentialing due date to begin the application process. Providers should be able to access all applications online.
The recredentialing process differs between states and organizations; however, it can often take weeks or months to complete. To expedite the process, healthcare organizations can keep required documentation on file and organization-specific requirements can be prepared ahead of time.
What Information Is Verified During the Recredentialing Process?
The following information must be up to date before the recredentialing process begins.
- State licenses
- Drug Enforcement Administration (DEA) or Controlled Dangerous Substances (CDS) certification Education and Training
- Board Certification
- Work History
- Malpractice Claim History
- Current Malpractice Insurance Coverage
- Hospital Admitting Privileges
- State Sanctions and Restrictions on Licensure and Limitations on Scope of Practice
- Medicare/Medicaid Sanctions
- National Provider Identifier (NPI) Number
What If A Provider Is Denied by the Credentialing Committee?
If a credentialing committee denies a practitioner’s recredentialing application, the practitioner will be notified with a written notice that includes reasons for denial and sources of data. Practitioners are entitled to submit an appeal.
If a provider seeks to appeal a decision, the provider should request reconsideration in writing within 30 days of the denial. Written requests should be submitted with supporting documentation. Reconsideration will be scheduled within 60 days of receipt. If denied a second time, the provider does not have any further recourse.
How to Maintain Recredentialing Documentation
In order to prevent recredentialing issues and the ensuing consequences, healthcare organizations should document and maintain evidence of the application in the practitioner’s credentials files. They should also develop a system to keep the information (which is subject to change) current.
Verisys provides continuous monitoring of a provider’s credentials and license status using the most comprehensive data in the healthcare industry. Verisys’ technology solutions for provider screening ensures compliance with proper documentation for recredentialing while reducing administrative strain on your organization. FACIS® (Fraud Abuse Control Information System) is a Verisys owned and maintained data platform. It is the number one trusted data platform and a nationally used database for screening and continuous monitoring against healthcare exclusions, debarments, disciplinary actions, and healthcare sanction screenings.
With constant monitoring by Verisys of over 5,000 databases, healthcare organizations can continue their work confidently with fully compliant providers. By leveraging premium technology, providers and healthcare organizations can be confident in the recredentialing process and continue to focus on providing premium patient care.
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|Written by Juliette Willard
Healthcare Communications Specialist
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