Quick and Efficient Physician Credentialing Services

Ensuring proper care and safety for patients is always paramount, and a crucial means of achieving this is through Provider Credentialing.

But what does it exactly mean? To attempt a simple definition, ‘credentialing’ is the meticulous process of verifying and evaluating the qualifications, credentials, and background of healthcare professionals before entrusting them with patient care.
In fact, as the healthcare landscape continues to evolve, the importance of robust provider credentialing cannot be overstated.

While healthcare professionals encompass a broad spectrum – ranging from physicians to nurses and various allied healthcare professionals – credentialing serves as an important safeguard, ensuring that those entrusted with patient-care possess the necessary qualifications and competencies that are required in their line of work.

The process involves a comprehensive review of the provider’s educational background, training, licensure, certification, work history, and other pertinent information. This scrutiny ensures alignment with the stringent standards and requirements established by regulatory bodies, healthcare organizations, and insurance companies. While meticulously assessing each provider’s credentials, healthcare entities aim to uphold patient safety while delivering optimal care outcomes. Patients can rest assured knowing they are receiving treatment from competent and qualified professionals who have undergone rigorous evaluation.

The information required for credentialing is dependent on payers but tends to be relatively consistent across the board and typically includes:

There are several organizations which handle the necessary information for primary credentialing. They include:

• National Practitioner Data Bank (NPDB)
• The National Student Clearinghouse
• Federation of State Medical Boards (FSMB)
• American Board of Medical Specialties (ABMS)
• The Office of Inspector General (OIG) and the System for Award Management (SAM)

Sunknowledge engages in a comprehensive range of provider credentialing activities, ensuring compliance and accuracy in provider directories while also addressing various regulatory requirements. Here is a summary of the credentialing activities that we perform:

1. Verifying Provider Details(1st and 3rd Quarter): In accordance with government mandate SB137, Sunknowledge ensures provider directory integrity by verifying provider details such as basic information, practice location, and insurance. Once the updated is done, the filled-out Provider Validation Form is uploaded into the system so that it gets updated with the current information of the provider.

2. Provider Health Plan Termination (Ad hoc basis): Upon receiving requests from groups, Sunknowledge processes health plan terminations associated with providers, including converting emails to PDF format and updating the system.

3. OIG-SAM-OMIG Process: We organize monthly checks for excluded providers from OIG, SAM, and OMIG directories for states like California and New York. This involves tasks like initiating the process, correcting errors, executing SQL queries, and sending confirmation email upon completion.

4. CMS Preclusion List: For monthly verification, we run an SQL query to ensure if the provider matches the list for California, Arizona and New York providers, updating the system accordingly.

5. Blue Cross Monthly Assignment: Monthly creation of reports for seven Blue Cross groups (RMG, LMG, ADOC, HDMG, HVVMG, SMG & GCMG) while ensuring their timely submission.

6. Ongoing Monitoring of DHCS Restricted Providers: We conduct monthly checks for DHCS restricted providers in California using SQL queries.

7. OIG Providers Monthly Assignment: We also run monthly checks to identify fraudulent activities by providers, utilizing the OIG website.

8. SAM Provider’s (Monthly Assignment)/EPLAS: We run monthly checks to identify fraudulent activities by providers, utilizing the SAM portal.

9. Weekly Monitoring of Medicare and Medi-Cal Suspension Status: Weekly monitoring of Medicare opt-out and Medi-Cal suspended providers by tallying with the last modified date and information available in the website.

• Providers State License – We support healthcare providers in acquiring and renewing state licenses, ensuring adherence to the regulatory requirements essential for practicing medicine or delivering healthcare services within specific jurisdictions.
• DEA Certificate & Renewal – Our services encompass the application and renewal procedures for Drug Enforcement Administration (DEA) certificates. This enables healthcare providers to prescribe and manage controlled substances in accordance with the requirements of their specialty.
• Maintenance of Provider Credentialing Files – We specialize in maintaining comprehensive provider credentialing files, ensuring they’re always up-to-date, well-organized, and easily accessible and more.Using remote desktop server to connect and perform all tasks related to credentialing, we provide reliable access to accurate credentialing data. But we don’t stop there. When you outsource credentialing to us, we handle the entire process efficiently. From credentialing through CVOs to reviewing doctors’ qualifications, preparing and submitting forms, evaluating referrals, and assisting with supplier acceptance, we ensure every aspect is managed with precision and compliance. Trust us to streamline your credentialing process effectively.