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Step by Step Road map for Medical Credentialing Services
Credentialing is the process of establishing the qualifications of licensed medical professionals and assessing their background and legitimacy.
Physicians and other healthcare practitioners who wish to bill an insurance company and receive reimbursement for services as an in-network provider must undergo a process of credentialing. This process, otherwise known as primary source verification, is the process in which an insurance company verifies the provider’s education, training, experience, and competency. In order to start this process, the provider must submit a credentialing application that details their training and qualifications to treat patients in their area. Once the verification is completed, the insurance company then decides if the provider meets its internal qualifications to serve as a provider of services to their insured members. After approval of a provider’s credentialing file, the insurance company then issues a participating provider contract that allows the provider of services to bill the insurance company and receive reimbursement as an in-network provider of services.
Medical Credentialing is used interchangeably to refer to insurance credentialing or provider enrollment. Medical billing credentialing services includes the primary source verification process at the payer or facility and the insurance contracting. Medical Credentialing is utilized by healthcare practitioners when they desire to participate with an insurance company such as United Healthcare or Medicare. Credentialing is a necessary process that needs to be understood and embraced by all practice that wishes for their providers to see patients and get paid.
Medical billing services, The processing of medical claims may span over just a few days to several months. On occasions, there are numerous forward and backward movements in the process, and this can occur due to errors in the initial registration and confirmation. Therefore, patient verification and authorization is a crucial step that may be performed on every visit. The primary objective of patient verification is to confirm financial responsibility for the medical services performed. Insurance coverage and plans differ significantly from carrier to carrier depending on the state and the premiums paid. Many healthcare providers hire medical billing and coding services providers to utilize their state-of-the-art technology and to avoid costly errors.
Start the Credentialing Process on Time:
Most of the times credentialing process can be done within 3 months, but that doesn’t mean you should take that long, as complications can arise. Payers have been merging into larger organizations. As a result, a practice’s ability to expedite an application has diminished. You’re working on the payer’s internal timeline for application processing, so it makes sense to allow additional time for any difficulties that occur.
Applications should be Complete:
According to research, only 15 percent of applications are complete, while rest are missing critical information required for processing. The most common areas of application deficits are missing data and obsolete data. Examples are:
Missing work history and current work status
Physician’s practice and effective date with the practice
Hospital privileges and covering colleagues
Malpractice insurance details
Update and Attest with CAQH:
The Coalition for Affordable Quality Healthcare (CAQH) started its uniform credentialing program about 15 years ago. Since then, most payers in the nation have adopted this program. Physicians who regularly follow and update with Coalition for Affordable Quality Healthcare find credentialing much easier. The Universal Provider (UPD) source is a part of CAQH’s credentialing application database project. Its goal is to make the provider credentialing more efficient for providers as well as for healthcare organizations.
Billing and insurance tasks contribute to a major portion of administrative costs for both providers and hospitals. Federally mandated CAQH CORE EFT and ERA Operating Rules also streamline and claim reconciliation.
Telemedicine is the future of the healthcare industry, more than 36 million Americans have already used some form of it. It’s estimated that 70 percent of doctor visits can be handled over the phone-costing far less than an in-person visit. The US military is one of the largest users, with about 55 percent of the Army’s telehealth program focused on behavioral health.
Each state has its own laws for timely credentialing, including in-state credentialing and reciprocity. Your state Medical Group Management Association can help you ensure you are adhering to your state’s standards and using them to your advantage. Your credentialing process will be easier when you gather all the information you need on new providers upfront.