Physician Credentialing: Worth Getting Right to Get Paid

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Physician Credentialing

Physician credentialing is the process of organizing and verifying the professional records that qualify a doctor to practice medicine. As physicians, despite your reputation for benchmarked medical services, you could be losing out when it comes to realizing medical bills reimbursed fully by respective health insurance carriers. And when you start to analyze that elusive reason responsible for hampering your reimbursements, you invariably end up discovering ‘Credentialing’ as the chief culprit.

Quite a contrast to the earlier scenario, wherein your credential as a qualified and competent practitioner could alone determine your practice’s sustenance and growth, the present-day scenario, characterized by innumerous practitioners and a heterogeneous mix of insurance carriers, requires your practices to bear the stamp of ‘Credentialing’ to stay well clear of audit, delay or denial exposures.

Although physician practices are required to be credentialed by Federal Health Agencies (for being compliant with requisite health care standards) as well as Medicare and Medicaid, and respective private insurance carriers (for being compliant with medical billing standards), it is the latter that assumes greater significance as it has a direct impact on operational optimization and revenue maximization. Credentialing in the medical billing context means that your medical practices are compliant with the benchmarked clinical and operational practices as deemed suitable by the prevailing health insurance convention.

As we stand at an important juncture when the health insurance sector is realigning its revenue structure after the Federal Government’s radical healthcare reforms, there is a growing emphasis being laid on Credentialing, first by the Centre for Medical Services, and then by private insurance carriers – making it mandatory for physicians to have their practices duly Credentialed.

But, owing to its exhaustive process, Credentialing itself could be one of your major preoccupations, relegating the all-important medical practice to the second! Here is the series of processes that would invariably have to clear to be eligible for Credentialing:

•  Preparation of paper CMS 855 & other Managed Care applications for all payers
•  Preparation and submission of online applications to federal and non-government carriers
•  New provider affiliations and Group Contracts
•  Maintaining and updating specific Provider information directly with carriers at frequent intervals or when requested
•  Resolving enrollment issues and tracking Managed Care contracts
•  Validating information provided by payers
•  Handling Provider letter of interest & enrollment transactions
•  The setting of Provider information in the Practice System
•  Obtaining Contracted Fee Schedules and negotiating changes
•  Preparation of contracting documents for scanning and long-term storage electronically
•  Preparing, maintaining, and monitoring Managed Care Summaries that provide effective dates, Fee Schedule details, and Group affiliation. Click Here: Physician Credentialing: Worth Getting Right to Get Paid