In this post, we’ll dive deep into credentialing to illuminate confusing areas and provide information vital to submitting your applications and negotiating your next partnership contract.

What is Credentialing/Contracting in Medical Billing?

Credentialing is an essential part of becoming a trusted healthcare provider by the endless list of insurance company venders out there in the marketplace.  Given that credentialing is a precursor to contracting, it can be incredibly important given many patients refuse to visit a physician not in their insurer’s network.

Providers want to expand their patient base by accepting new patients with specialized insurance plans. To do this, they must first meet the rigorous rubric of requirements set by those insurance providers…AKA shuffling endless amounts of paperwork back and forth often using online resources such as CAQH/PECOS.

Once they successfully complete the application process, a provider can move onto contracting and towards receiving insurance reimbursements for services rendered under the in-network provider status. The insurance company calls this process credentialing/contracting.

Credentialing, also called primary source verification, is an intensive process whereby the insurance company conducts a background check on the physician. They verify the healthcare provider’s education, competencies and legal authorization to practice medicine.

Turnaround times for credentialing vary, as there are a number of factors at play. Medicare, which utilizes its own Provider Enrollment, Chain, and Ownership System, actually approve credentials for providers faster than commercial insurance carriers, with a 41 day average.  Credentialing through commercial carriers ranges anywhere from 60-180 days, with the possibility for exceptions. This is a hurry up and wait game…so be ready to wait.

If everything checks out, then the insurance company extends a partnership contract to the provider to include them in the network of providers.

It is unlikely that a commercial insurance carrier will apply in-network status for claims filed prior to the credentialing. To avoid uncovered claims, submit the application promptly and ensure all information is correct.

The Application Process   

Achieving in-network status begins with an application. When submitting an application, ensure you have the most up-to-date version of the insurance carrier’s application form. Using an outdated version can result in application delays or even denial.  Ensure that all sections are complete. Any hiccup in paperwork means a delay in processing…which means more time until you get that in-network status.

If required to submit supporting documents, double check that they are attached to the application.

From time to time, things can get lost in transit. Keep a copy of all credentialing application materials that you submit.

Include All Relevant Information

Though a touchy subject, it's important to provide complete details regarding any medical malpractice insurance claims filed.

Insurance companies will check during the credentialing process. Lying or omitting this information hurts your application.  The National Practitioner Data Bank maintains a database of all medical malpractice insurance claims filed, so insurance companies will know when an applicant is withholding this type of information.

Confirm the accuracy any outstanding reports submitted on your physician’s behalf. Also, ensure any adjustments or updates are corrected through NPDB.

Follow Up Is Important

It may go without saying, but following up with the insurance provider to learn the status of a credentialing application is highly important. Again, hurry up and wait…just be sure they got what you sent too.

Make a quick phone call to ensure the proper person or department received the application materials. In 2-3 weeks, place another follow up call to confirm that they’ve received all required information. Proactivity often reduces credentialing time, so stay on top of things!

The Pitfalls of Self-Credentialing

Credentialing in medical billing can be tedious, cumbersome and time consuming.  Trying to navigate the credentialing process is overwhelming and often costs more time and money than working with a professional that is knowledgeable of the process and can advocate on behalf of the provider.

Oftentimes, providers are too busy healing patients and handling the administrative needs of their practice. They don’t have to complete credentialing applications. The Auctus Group handles everything from contracting and credentialing to medical billing and bookkeeping. Contact us to learn more.

 

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