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IKE[By Ike Devji  JD]

Many medical practice employees, including doctors, nurses, and various clinical assistants must be very specifically credentialed based on both the specifics of your practice and third-party payer contracts.

This additional condition of employment requires a variety of credentialing compliance best practices.

Why is This Such a Big Deal, What’s the Worst that Could Happen?

  • Once an error is identified in any one area of your billing practices, you should expect other areas, even non-related ones with lower compliance burdens, to be examined;
  • You face potential civil and criminal liability for billing third-party payers that contractually require specific credentialed care providers;
  • Your practice may face a loss of revenue due to failure to comply and substantial disruption of practice cash flow if an audit or questions arise;
  • You are subject to reputational damage, stress, and substantial legal fees easily in the six-figure or seven figure range;
  • Increased medical malpractice risk for potentially not providing the required reasonable standard of care if a non-credentialed employee is in the chain of treatment for an affected patient;
  • It may also potentially induce your liability insurance carriers to either completely exclude an event or reduce applicable coverage.

Although this process can be managed internally with the right training and by a variety of existing administrative staff, there is professional help available at nearly every scale, from small practices to hospitals. Many practices, especially smaller ones that don’t have full time HR managers, find that outsourcing this issue is a time and cost efficient form of risk management of this important issue. Outside professional resources are generally known as credentialing organizations (COs), which operate under the wider banner of HR and employee background-check services. Many of these services have accredited certified provider credentialing specialists that can work with your office and staff as outsourced compliance experts.

The biggest benefit a CO can offer is that the best of them go beyond providing just a snapshot of your current credentialing; they also offer a long-range plan to help you implement and maintain it.




Some Advantages of Outsourcing this Issue to a Credentialing Organization

  1. They manage credentialing proactively instead of reactively and can help avoid loss of time, efficiency and revenue when, for instance, doctors or staff are taken out of the office to complete massive amounts of CME all at once on a short deadline;
  2. COs are typically better equipped to respond quickly to staff changes including the on-boarding of new staff or doctors, and can help identify and verify what is required to bring any new staff into compliance;
  3. They typically have software systems that are more consistent and reliable than the self-created systems implemented by most practices internally, typically Excel spreadsheets that need to be manually updated and checked;
  4. Using CO software systems is often time and cost efficient in related areas, like insurance credentialing and can help manage a variety of functions including background check compliance, immunizations and hospital privilege policy compliance, as just a few examples.

Risk management in this area again requires that your practice is proactive and discovers and corrects any credentialing gaps in your office before they are an unwelcome surprise discovered by a third party. The liability and financial jeopardy is ultimately that of the practice owners and managers regardless of whether you outsource to a CO or not.

Proactively addressing this serious issue starts with a few simple steps:

  • Have a specific written plan to determine and verify all the required credentialing compliance of each employee and to maintain their compliance status. This applies to both statutory compliance required by law and any other credentialing required as a provider that bills third parties under specific and enforceable contractual requirements;
  • Make a specific person accountable for managing this process and check on that management at least quarterly;
  • Implement appropriate specialty insurance coverage where possible to help protect against any gaps or errors including RAC audit insurance.




Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.


Mr. Ike Devji is Of-Counsel with Lodmell & Lodmell PC and is the firm’s former managing attorney. He is the Executive Vice-President of the Wealthy 100 ™, a Phoenix Arizona based wealth management and wealth strategy firm with a network of advisors across the United States.  Mr. Devji selectively consults and provides asset protection services to high-net worth, high liability clients nationwide. Ike has spoken to literally thousands of physicians, allied medical professionals and other high-net worth clients across the country. He provides continuing legal education on this subject to other attorneys and regularly lectures at the request of leading medical practice management and investment management groups, including most recently; MultiFinancial Securities, Greenbook Financial, ING, ING TRUST, Comprehensive Wealth Management, CFO Advisors, numerous banks, and both Lorman and the National Business Institute, among others.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com




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One Response

  1. 5 Ways to Avoid Hiring Mistakes for Financial Advisors

    RIA firms looking to grow need to develop a strategy when looking for new talent, according to Kelli Cruz.


    A slide show.



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