Everything You Need To Know About Credentialing Services In Medical Billing

If you have just started your medical practice then you need to learn more than you’ve got in your medical college. Because a healthcare business involves much more than the medical obligations to be successful in the highly competitive industry. In this article, I’ve highlighted every administrative aspect that is involved in a successful healthcare facility and that’ll help you organize your business operations in a better way.

In order to dive into the concept of credentialing services,  here I would like you to suppose a situation; When a patient comes to visit the physician’s office. He/she provides complete information to the registration staff and notes down everything in a document. Have you ever thought about what is the purpose of this document? Simply, this information is used as an insight into a detailed healthcare revenue cycle management system.

The first step of this system comprises verification of the information, where the medical staff verifies whether or not the patient is eligible for any insurance plan. Now here comes the concept of credentialing services into the picture.

Credentialing/ Contracting In Medical Billing:

It is the most important component of the healthcare industry. It helps physicians/ lab technicians and other medical care providers to claim their reimbursements from the right insurance payers. In this process, the administrative staff realizes that the patient is getting medical/diagnostic services from the in-network healthcare provider.

For this purpose, they also ask patients to sign a contract to submit an application. This contract will help physicians to submit medical claims to the insurance company so they can reimburse them in return.

If there would be any mistakes or errors in the contract or credentialing process then it won’t allow physicians to earn their reward for their patient care services. So, it needs greater attention and expertise to make sure the whole medical billing process goes streamlined beginning from the credentialing process

Primary Source Verification:

Credentialing services AKA primary source verification allows practitioners to increase their customer base who have particularly specialized insurance plans. It allows them to understand and meet the requirements of insurance companies and generate increased revenue. Otherwise, if practitioners won’t have proper medical billing solutions that can improve the credentialing process then they would have to spend most of their time shuffling papers. Their practice would become like a patient comes to visit the doctor and then the physician gets into the trouble of using online resources such as CAQH/PECOS to find out the application form for credentialing.

If they would have up-to-date solutions then they could easily process their applications and the healthcare provider can shift towards the contracting and claim submission process. However, if the provider won’t get the right information about the insurance plan or the insurance company then he/she would never become able to find their source of reimbursements. Therefore, it is the primary responsibility of every healthcare provider to make sure that they verify the in-network status of their healthcare practice from the patient’s demographic information by executing the process of credentialing/contracting.

Another reason why credentialing is also known as primary source verification because it can help you to learn about the background of the physician’s practice. Hence, the patients and insurance companies can also verify the medical care provider’s qualifications, practice experience and legal authorization.

Optimized Time:

Every medical specialty has a turnaround time for the completion of the credentialing process. Hence, it varies for different healthcare practices depending upon the number of different factors. Medicare also uses its own set of Provider Enrollment rules, Chain and Ownership System _ that actually approves credentials for providers within an average of 41 days that is lesser time than the commercial insurance carriers.

When you get credentialing services from commercial carriers ranges anywhere from 60-180 days and there is always a room for expectations. Therefore, practitioners must follow a single rule of thumb “hurry up and then be patient”. So you should get ready immediately to wait for a long time period.

It has never happened ever before that any commercial insurance marks an in-network status for any healthcare provider without the proper execution of the credentialing process. Therefore, practitioners need to adopt effective medical billing solutions that can optimize the credentialing services and prevent you from claim denials. Most importantly, submit applications in a timely manner and always mention the right information on the medical billing claims.

Ensure Accuracy In The Application Form:

If you’re a healthcare practitioner who wants to gain an in-network status then you should start right from the application process. You need to make sure that you’re using the most up-to-date application form of an insurance company before submitting the application. If you’d be using an outdated version of the application form of an insurance company then it would result in claim denials. Ultimately, you won’t be able to generate income from your patient care services.

If there is any mistake in the paperwork then it’ll cause a delay in the billing process which means that you have to wait longer to achieve that in-network status. Even if it requires some supporting documents that you need to attach those documents after proper verification. Remember, “there is no room for errors in the successful medical billing process”.

Otherwise, it’ll cause claim denials, rejections and revenue loss. Although things get changing with the passage of time. Therefore, always prepare a copy of credentialing application materials every time you submit an application form. So you can have a full record of documentation of how many claims you’ve submitted and how much revenue you have to collect from insurance carriers.

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