Did you know that APPs now make up 41% of the country’s provider workforce, and are actively involved in both surgeries and primary care? In fact, their inclusion in healthcare has had such a positive effect that their demand keeps growing. According to the Bureau of Labor Statistics, nurse practitioner jobs will grow by 46% by 2031, while physician assistant jobs are expected to grow by 28%.
But who are APPs really, how are they different from physicians, and how does credentialing (with its requirements, challenges, and best practices) play into all this? You will find out all this and more in our detailed guide to APP credentialing. So continue reading, as we reveal the answers one by one.
Who are Advanced Practice Providers (APP)?
Advanced Practice Providers (APPs) are non-physician clinical staff in the U.S. healthcare systems who have specialized training and licensing to diagnose, treat, and manage a range of medical conditions.
Although they are not medical doctors (MDs), they still wear a white coat and perform a variety of everyday clinical tasks, such as ordering radiology tests, conducting physical exams, taking patient history, reviewing test results, managing treatment plans, prescribing medications, assisting with biopsies, and making referrals to other healthcare practitioners. Still confused? Okay, maybe this will simplify things. When you meet one of the following, know that they are a part of the group called APP.
- Nurse practitioner (NP)
- Physician assistant (PA)
- Clinical nurse specialist (CNS)
- Certified registered nurse anesthetist (CRNA)
- Advanced practice registered nurse (APRN)
- Certified nurse midwife (CNM)
- Advanced dental therapist (ADT)
APPs’ Role in the Broad Healthcare System
Before the 1960s, non-physician staff, especially nurses, worked under the direct supervision of a physician. But in 1965, Dr. Loretta Ford and Dr. Henry Silver developed the first nurse practitioner (NP) program at the University of Colorado. This educational program aimed to advance the role of nurses and train them to independently carry out clinical tasks like disease assessment, diagnosis, and treatment in primary care.
Thereafter, several educational programs were introduced in the USA to train, certify, and license individuals in non-physician roles. This initiative was a countermeasure to healthcare staff shortages and physician burnout, and showed positive results in accelerating quality care delivery.
APPs are trusted healthcare practitioners who can independently manage a wide range of patient needs. Like physicians, they are required to renew their licenses, advance their education, obtain board recertifications, and get credentialed/re-credentialed with insurance payers.
So, let’s explore advanced practice provider credentialing to understand what needs to be done before these practitioners render care services to patients and bill payers.
Credentialing Requirements for APPs
Credentialing for advanced practice providers is more or less the same as it is for physicians. However, because of differences in their education level and job experience or job description, the credentialing requirements for APPs are slightly distinct from those of physician providers.
So, here is a detailed breakdown of the APP credentialing requirements:
Education Verification
Most APPs are required to have at least a graduate-level training and therefore should have a Master’s degree from an accredited program to prove it. For example, an APRN must have a Master of Science in Nursing (MSN), whereas a PA must have either a Master of Science in Physician Assistant Studies (MSPAS), a Master of Physician Assistant Studies (MPAS), or a Master of Health Science (MHS).
Note that many of these specialized graduate programs include both components, classroom instruction and clinical rotations. So, that’s approximately 3-4 years of higher education and over 2,000 hours of clinical experience.
Liscensure
Next, an APP must have an active license in the state where they are practicing. For example, an NP must have an active registered nurse (RN) license, whereas a CRNA must hold an unencumbered registered nurse license or a state-specific APRN license.
National Certification
For APP credentialing, the individual must have also passed a certification exam from a recognized body. For example, to become a CNM, passing the American Midwifery Certification Board (AMCB) exam is a must. On the other hand, a PA must submit proof of passing the Physician Assistant National Certifying Exam (PANCE) for credentialing.
DEA Registration
As we mentioned earlier, APPs are frequently involved in the creation or changes to treatment plans. Therefore, they are eligible to prescribe medications. However, they must be federally authorized to prescribe controlled substances, and for this, they need a Drug Enforcement Administration (DEA) license.
Professional Documentation
APP credentialing is a mandatory first step for obtaining clinical privileges, or in other words, to become a recognized working professional in the healthcare space. For that, all applicants must submit their updated curriculum vitae (CVs), their National Provider Identifier (NPI) numbers, tax information, malpractice insurance coverage, and referral letters (if required).
Clinical Competency
For advanced practice provider credentialing, payers also want to see proof of clinical competency. Meaning, they want assurance that the applicant is capable of providing safe, effective, and ethical patient care. For this, they may ask the applicant to submit proof of experience (internship or residency), clinical logs, and proctoring (peer-reviewed evaluation).
Criminal Background Check
Last, but not least, payers also perform a thorough state and federal criminal background check of all applicants submitting an APP credentialing application. This means the applicants are also verified against the sexual offender registry, along with malpractice records maintained by state medical boards and court systems.
So, here, the applicants’ job is to provide accurate information, the reason for license revocation (if applicable), and proof of rehabilitation if they were penalized for any offences or malpractice.
APP Credentialing and Enrollment Process for Medicare
Advanced practice providers must enroll with Medicare if they wish to offer care services to Medicare beneficiaries and bill Medicare for reimbursement. The enrollment process is straightforward and outlined below:
- You must obtain an NPI number from the National Plan & Provider Enumeration System (NPPES).
- You must enroll in the Medicare program by creating an online profile on PECOS or submitting a paper-based CMS-855I application.
- You must then register for an account in the Identity & Access Management (I&A) System to manage access to NPPES, PECOS, PEPPER, and CBR, manage staff, and authorize others to access your information.
After successful enrollment (which will be confirmed via PECOS), you are eligible to see Medicare-covered patients and bill the federal payer for your services.
Unique Challenges in APP Credentialing
The following are some of the challenges advanced practice providers frequently encounter when submitting credentialing applications and waiting for approvals.
Rejection of Inaccurate Applications
APP credentialing applications with inaccurate or missing information are immediately rejected. Moreover, the payers want documented evidence to match all the information stated in the application form. So, for example, if the educational certificate has a different name from the applicant’s or the dates don’t match, the application will be rejected.
Lack of Standardization
Another major problem that applicants face when undergoing advanced practice provider credentialing is that requirements are inconsistent across insurance payers and states. For example, the malpractice insurance rate for an NP and a PA might be different in the same state. And for an NP, the rate might vary in Alabama and Massachusetts depending on the state laws. So, it becomes quite difficult and time-consuming for APPs to navigate these varying rules and requirements.
Lengthy and Time-Consuming Process
Because of the many requirements and several verification levels, APP credentialing becomes a time-consuming and lengthy process. Moreover, the delays in credentialing are proportional to the delays in patient care. Why? APPs cannot secure clinical privileges unless they are credentialed, and unless they get clinical privileges, they cannot see patients. Hence, the wait times keep increasing, and patient dissatisfaction keeps rising.
Slow Primary Source Verification
The next challenge that arises in the process of APP credentialing is the delay in obtaining verification of credentials from external bodies, such as medical schools, national exam committees, licensing boards, and other relevant authorities.
After reviewing the credentialing application, payers contact the listed primary sources to verify or corroborate the applicant’s credentials. It is an essential step in ensuring that everything the applicant has stated in the application is the absolute truth. However, the primary sources are often slow to respond to these requests, which stalls the APP credentialing process.
Data Maintenance Issues
To this date, many healthcare practices across the USA maintain manual records or hard copies for their patients and staff. This results in data loss, inefficient record-keeping, and hours of work in consolidating everything in one place. The real challenge? When it is time for credentialing for an advanced practice provider, the practice has a hard time entertaining their request for clinical logs, evaluation reports, and experience details. As a result, the APPs encounter delays in obtaining the required documents and filing their credentialing applications.
Recredentialing Every 3 Years
The last but most significant hassle of APP credentialing is that providers must get re-credentialed with the same payer every 2-3 years. You read that right. In the professional lives of healthcare practitioners, nothing is “one and done”. From their education to board certifications, and licensing to credentialing, everything must be renewed and kept current. So, the same credentialing process, along with its long list of requirements, is repeated triennially.
APP Credentialing – Best Practices
Now that we have discussed some of the challenges that advanced practice providers frequently encounter during credentialing, let’s explore some workable solutions to overcome them.
Centralized Data Management
First and foremost, advanced practice providers should consider using centralized databases or software for data and document management. It streamlines the whole process and improves efficiency by storing everything in one place.
Moreover, many insurance payers already use digital databases, such as CAQH ProView, for credentialing. All that the provider is required to do is to create their profile, re-attest it every 120 days, update their information and credentials (when necessary), and give the payer authorized access to their profile if they wish to credential with them.
You be the judge. Doesn’t that sound simpler and more time-saving than keeping manual folders, printing out required documents each time, and mailing the APP credentialing packets to the relevant payers?
Automating Application Submissions
Several specialized credentialing software are now available in the market that use artificial intelligence (AI), robotic process automation (RPA), and API integrations to automate the entire credentialing lifecycle.
These applications (e.g., CredentialStream and MedTrainer) can be used for advanced practice provider credentialing to autofill applications, exchange data with primary sources, communicate with payers, and track application progress. From interactive dashboards to data syncing and auto-attestations, these applications allow you to perform a myriad of credentialing functions.
Proactive Monitoring and Communication
Whether your APP credentialing process is manual or digital, one thing is non-negotiable: proactive follow-up. You must monitor and follow up on the progress of your application to avoid surprise rejections.
Many times, payers stop reviewing an application midway because they want more information or supporting documents from you. However, you may miss their request due to an inactive email ID, a busy schedule, or some other reason. In this case, the application gets delayed because of you. Therefore, it is your responsibility to maintain effective communication with the payer and inquire about the reason for the delay.
Outsourcing APP Credentialing
We get it. All of the above is easier said than done when you are working 12-hour shifts each day. Moreover, as a non-physician staff member, you may not even have the capital and resources to invest in automated credentialing systems to streamline the process. But there is a workaround for you, too. You can outsource APP credentialing to third-party companies for rates as low as $200 per application.
In this all-inclusive price, they manage everything for you: from meeting payers’ credentialing requirements to submitting applications and tracking their progress. Sometimes, the package fee may even include re-credentialing as a complementary service. So, it might be worth a try.
Streamline APP Credentialing with MediBillMD
There you have it, a comprehensive guide on advanced practice provider credentialing. But before we take your leave, let’s go over the key takeaways.
APP credentialing is similar to physician credentialing, with minor differences in the required documents and referrals (educational and professional). The process may take a few months and involves several steps, such as the collection of necessary documents, creating online profiles, submitting an application, waiting for primary source verification, and tracking the application progress. Although credentialing is hasslesome, it is the first step that non-physician providers must take on their career-long journey of insurance billing. Without getting credentialed, advanced practice providers cannot get clinical privileges.
The good thing is that now, you no longer have to carry the burden alone. MediBilMD employs an experienced team of credentialing experts who can handle your applications and get you enrolled with any payer of your choice. So, explore our nurse practitioner credentialing services for details.
