Credentialing in Medical Billing could be the one thing that stands between you and reimbursements.
According to the Medical Group Management Association (MGMA), around 54% of medical practices agree that the rate of claim denials has increased because provider’s credentials are not approved by insurance payers.
Don’t let this be your story. Learn everything that you need to know about credentialing in medical billing to get your rightful payments and keep your practice alive.
What is Credentialing in Medical Billing?
Medical credentialing, also known as physician credentialing, is a compulsory process. It ensures that only verified, attested, approved healthcare professionals are enlisted with the insurance payers for fast reimbursements.
During this process, payers assess a healthcare provider’s qualifications, certifications, licenses, affiliations, and more to determine if they will be capable of delivering quality healthcare and adhering to industry regulations.
Only those providers who are credentialed and enrolled with the payers get reimbursed for the services rendered to their plan holders (patients with an active insurance plan).
Healthcare providers are also required to undergo medical re-credentialing once every 3 years.
PRO TIP:
It must be noted that medical credentialing is a broad and confusing term. It encompasses insurance credentialing and hospital credentialing services for healthcare providers. However, when speaking of credentialing in medical billing, we only refer to the insurance credentialing process and not the vetting process that professionals must undergo to join a hospital.
Types of Credentialing in Medical Billing
Healthcare providers are generally offered 3 types of medical credentialing services, as discussed below.
Initial Credentialing
Usually offered to new providers in the healthcare space, this service entails submitting the required paperwork, such as academic qualifications, licenses, and certifications, to the payer they wish to enroll with.
Re-Credentialing
Established providers must re-credential or re-verify their work experience, qualifications, and licenses every 2 to 3 years to retain enrollment in the payer’s network. It is done to ensure that the provider continues to meet the standard of healthcare expected of him/her.
Provisional Credentialing
It is a temporary or transitional verification offered to healthcare providers who are new to the network. Provisional credentialing allows healthcare providers to collect reimbursements from the payer without fully integrating into the network. It can also be an in-between until the payer completes the provider’s credentialing process.
Credentialing Process in Medical Billing
The 6-step credentialing process in medical billing is easy to follow. However, one mistake and it could take weeks to enroll in the payer’s network, bringing your revenue cycle to a standstill.
Step # 1 – Confirming Eligibility
The first step is to check if you are eligible to enlist as a verified provider in the payer’s network. To be eligible, you must be a licensed healthcare professional and have a National Provider Identifier (NPI) number and a Tax Identification Number (TIN).
While the above prerequisites are standard for enrolling in the Medicaid payer network, private payers’ eligibility criteria may be different for each insurance company. So, it is wise to check the eligibility criteria for medical credentialing on their official websites.
Step # 2 – Information Gathering
The next step is to collect all the information and required documents For example, you will need documentation for:
- Medical diplomas and degrees
- Valid medical license
- Board certifications
- DEA registration
- Affiliation letters
- Criminal records
- Work history
- References
And more.
Step # 3 – Application Submission
This can be the easiest or the trickiest part of the credentialing process, depending on your level of preparedness. If you are ready with all the required information and supporting documents, then filling out an e-form and attaching the soft copies is fairly easy.
However, if you miss the 2nd step and start filling out the application form, it could take days to compile all the paperwork and attach it as required.
Step # 4 – Waiting for Approval
After applying for medical credentialing, you must wait for the approval. Depending on the payer and your state, it could take between weeks and months to get approved.
During this time, the payer may ask for additional documents or schedule a site visit to confirm the legitimacy of your practice.
Step # 5 – Completing Enrollment
Once approved, you must complete the enrollment process by signing a Contract Agreement with the payer.
It is a binding document that indicates that the payer and provider have agreed on the terms and conditions related to covered healthcare services, claim submissions, payments, and denials.
Step # 6 – Monitoring and Renewals
The final step of the credentialing process requires you to be proactive and maintain strong communication with the payer.
You must diligently monitor any changes in the payer’s policies, abide by the regulations, and submit an application for re-credentialing after 2 or 3 years to stay on the top of their list.
Common Credentialing Errors in Medical Billing
Credentialing in medical billing can be a complex and time-consuming process, even for the most accomplished and experienced physicians. The chances of errors are high, especially when every step of the process requires attention to detail.
Let’s discuss some of the most common errors that occur when credentialing for medical billing.
Incorrect Data Entry
Providers often make unintentional typing mistakes while filling out the medical credentialing application form. Incorrect data entry, such as wrong names, dates, or identification numbers, can delay or jeopardize the credentialing process, affecting the providers’ revenue streams.
Inaccurate or Incomplete Documentation
When providing supporting documents, providers tend to attach the wrong files or do not provide sufficient documentation to back up their credentials. It, again, hinders credentialing in medical billing.
Regulatory Non-Compliance
Another big mistake that healthcare professionals make when applying for medical credentialing is that they conceal instances of malpractice or previous disciplinary actions. It constitutes regulatory non-compliance, and providers could be penalized for fraud, leading to a lifelong ban.
Neglecting Re-Credentialing
The field of medicine is ever-evolving. Healthcare practitioners must constantly undergo training, renew their licenses and certifications, and stay current with affiliations to keep pace with the changing industry trends. Therefore, re-credentialing becomes compulsory to notify payers about upgrades in the provider’s academic record or work history.
Importance of Credentialing in Medical Billing
Credentialing is the setting stone in medical billing on which patients, providers, and payers erect their pillars of trust.
Ensures High-Quality Healthcare
This comprehensive vetting process ensures that all the providers entering the insurance payer’s network have the necessary qualifications, skills, experience, and a clean record to guarantee quality healthcare to the plan holders.
Moreover, payers can rest assured that the providers will abide by the industry regulations and payer policies, preventing unnecessary legal actions for the smooth functioning of the healthcare system.
Boosts Patient Satisfaction
After credentialing, healthcare providers become an ‘in-network provider’ on the payer’s panel.
Patients consulting in-network providers get the confidence that the physicians treating them are reliable and one of the best in their fields. It automatically elevates patient satisfaction, and after continued positive provider-patient encounters, the trust only grows deeper.
Guarantees Higher and Faster Payments
Healthcare providers should not even render care services to insured patients without undergoing medical credentialing. In case they do, their medical claims for reimbursements will be denied because insurance payers do not reimburse out-of-network providers, resulting in write-offs. Therefore, for accurate and timely reimbursements, credentialing is important in medical billing
Regulatory Requirements for Credentialing in Medical Billing
Some of the regulatory requirements that providers must adhere to are as follows:
- Compliance with state and federal laws
- Renewals of licenses and board certifications
- Obtaining a Drug Enforcement Administration (DEA) number
- Getting an NPI number
- Having a Tax Identification Number (TIN)
- Keeping updated procedure logs and clinical history
Besides these, providers must understand that credentialing is compulsory for participation in Medicaid and Medicare programs, and non-compliance could lead to legal implications.
Conclusion
Credentialing in medical billing is the process in which insurance payers thoroughly check and affirm the healthcare provider’s credentials – academic background, work experience, certifications, licenses, affiliations, etc., before signing a contract with them.
It paves the way for smoother provider-payer partnerships and enhances patient satisfaction as insured patients receive quality healthcare from vetted and verified physicians.
Therefore, credentialing should be the first thing on healthcare providers’ minds if they seek rightful reimbursements for their services.
