OVERVIEW AND TIPS FOR PROVIDER CREDENTIALING PROCESS

Provider credentialing is critical for authenticating expertise, experience, willingness, and interest in providing medical care. If you are not able to follow the provider credentialing process, it can result in delay or worse, denial of the provider payment.

Provider Credentialing Process

It is not one of the formalities that you have to complete or a form that you need to fill. It is an ongoing process that involves a lot of complexities. Therefore, you need to closely follow all the requirements. There are many steps that you need to follow in order to qualify for credentialing. Also, it is essential for your business that you practice without any hindrances.

Besides the simplistic definition, it also involves submitting a lot of documents and forms to various third parties for verifying your practice. You do not need to follow the entire process each year. However, you must provide annual updates.

Some Tips to Keep in Mind When Credentialing

Here are some tips that you need to consider when going for provider credentialing.

Do Not Wait

You can mostly complete the process in three months’ time and take up to five months to complete the entire process. You can no more expedite and shorten the process but abide by the regulations and others’ timelines. The timelines of the payers may vary, so do not wait for initiating the application process.

Be Careful With Requirements

Most of the applicants lack critical data for processing the complete application. Here is what a Credentialing Manager has to say about the state of applicants’ affairs.

“85 percent of applications are missing critical information that is required for processing.” Missing, outdated, or incomplete information is most common in the following four areas:

  • Work history and current work status (include the physician’s effective date with your practice);
  • Malpractice insurance;
  • Hospital privileges and covering colleagues; and
  • Attestations.”

Furthermore, he also points to the fact that applicants can avoid delays by taking care of these small mistakes. Therefore, the applicants must try to get it right the first time.

Shopping infographics. Process chart, step diagram, template. Creative concept for infographics, presentation, project. Can be used for topics like shopping, marketing, research.

Stay Updated on CAQH

CAQH (Council for Affordable Quality Healthcare) has been running its program for the last 18 years. Most of the providers are already following this program. Therefore, the new as well as established physicians, who are adopting this program, have a lot of ease in credentialing and re-credentialing.

Give a Provider’s Start Date

Many healthcare providers remain reluctant when it comes to asking new physicians to submit requisite credentialing paperwork. The health service providers may think of short-term benefits. Therefore, they need to focus on complying with the requirements to avoid any delays or worse, denial of the payments. Furthermore, it is also better for new physicians since they can grow their practice a lot faster.

State Regulations Are Important

The reciprocity and other regulations differ from one state to another. If a physician is credentialed in one state, their credentialing can be updated in another state. However, if a physician moves from one practice to another, they do not require any update to the entire credentialing process. If a physician moves from one state to another and they are not sure about the details, they need to get in touch with their respective Medical Group Management Association. This information will help the physician use the state’s standards to your benefit.

Success Factors to Take Into Account

CAQH Universal Provider has the most comprehensive data source. It is also accepted across the United States as the most detailed credentialing database. By filling their form you will be able to find all the necessary details that you require. However, if you feel tempted to leave some of these fields blank, you are only increasing your chances of rejection. If you fail to realize that, it would be months before you are able to know about the rejection. Once you get the bad news, you would have to provide updates in a very short time. Therefore, it is better to complete the requirements of all the requisites. Do not rely on your memory for estimating dates or other vital clinical data to fill.

Be Careful About the Form Filling Process

Many still believe that it is OK to bill under some other physician’s name when you are waiting for the credentialing process to complete. If you tend to fall for this suggestion, you are subjecting yourself to potentially big legal problems. A lot of the contracts explicitly forbid the physicians to file under someone else’s name. Health providers must also keep a check on the total denials so that they can follow a careful course of action accordingly.

As credentialing and enrollment agents, P3 requires a copy of your National Provider Databank File and requests for credit report information. It is critical to the process of credentialing to run thorough criminal background checks in addition to the procedure of primary source verification. Despite discrepancies, P3 Healthcare Solutions, Ontario, CA assembles a comprehensive case to help you settle down in your new workplace.

HOW TO AVERT MEDICAL BILLING CLAIM DENIALS?

Medical billing denial is the rejection of a claim by an insurance company made by an individual or by the provider, to pay for the rendered health care services. If you are a financial administrator in a hospital or any other healthcare facility, you would have an idea about the complications involved in medical billing claims. The denial of claims proves to be a continuous headache as it affects the credibility, cash flow, and the overall efficiency of a healthcare provider.

Studies suggest that the annual claim denials for hospitals stand at 2 percent, whereas, for medical practices, the percentage increases up to 10 percent. It makes medical practices less profitable by comparison.

Some of the healthcare organizations even undergo denial rates of 15 to 20 percent, which is considered extremely high. It means that providers facing this kind of denial rate have one out of five medical billing claims denied.

In addition, the providers have to spend a net amount of $25 for every denied medical billing claim.

However, you can avoid most of your medical billing denials by taking simple precautionary measures. They might not vanish completely, but the steps below assist in minimizing them. The underlying fact is that reducing them even by 1% has a massive impact on lowering provider’s accounts receivable.

Let’s go through the measures we need to take to reduce medical billing claim denials.

  1. Categorizing and Quantifying Medical Billing Denials

Providers can reduce receivable claims by properly analyzing, calculating and reporting patterns of different healthcare providers, departments and payers. These analytical measures are essential to run an efficient medical billing management system.

  1. Create a Professional Task force

Put together a task force to analyze and rectify medical billing trends. It is also important to find out which trends are worth looking into and which are not. Well educated and trained team of professionals can quickly streamline the medical billing process for the provider.

  1. Organized Data Portals

Organized patient data portals handle information in a more structured manner. Make sure to design a smooth registration process. Otherwise, it may lead to errors resulting in medical billing denials.

  1. Find Out Reasons behind Denials

You need to find the root cause of denial. For this purpose, you have to go beyond any coding clarifications and design different analytical techniques.

  1. Use Updated Claim Management Software

It is important to ensure that all the edits made are functional, recent and contribute to a continuous improvement cycle. This improves the overall claim recovery rate. Pick up a vendor that can provide you with better claim recovery rates.

  1. Automated Predictive Analytics

It is crucial to flag potential medical billing denials and rectify any errors before claiming the medical bill. The automated predictive analytics help quickly identifies incomplete medical billing claims.

  1. Work Alongside Payers

Providers need to work with payers to eliminate the specific contract requirement which may lead to medical billing denial. Data analytics can help determine the trouble spots and falsely navigated support systems.

The best way to reduce your accounts receivable is to identify the reasons leading to medical billing claim denials. Medical billing and coding plays a vital role in the acceptance or rejection of claims. Staying alert and always on the lookout for billing mistakes, removing them, and taking measures so that they don’t happen in the future increases a provider’s credibility.

P3 comes up with medical billing services for clinicians across various specialties. It is not always the technical skills that matter but the will to complete a certain task. We have the passion to deliver results on behalf of doctors when it comes to billing or the Quality Payment Program.