Posted by The credentialing of a healthcare provider is correlated to the cash inflows or reimbursement from insurance companies. A delay or expiry of credentials can affect the revenue cycle process of the company. In recent changes in payment methods, MACRA or MIPS has increased the importance of credentialing. If your credentialing is not completed or you have not gone through re-credentialing after the expiry, it may lead to heavy revenue losses.
What is Credentialing?
Credentialing can be defined as a process through which the qualifications of a licensed professional organization are established. In simple words credentialing is the required paperwork for insurance companies. Healthcare professionals or companies conduct credentialing on themselves or through a medical billing company.
If you are not credentialed with an insurance company probably, you are missing a large share of your medical business.
Credentialing Includes
- Verification of Documents
- Privilege to perform specific treatment procedures
- Get enrollment in insurance providers. After enlisted in the panel of insurance providers, you can sign a contract and negotiate to receive payments.
Credentialing step-by-step
First step:
- Fill out the credentialing application.
- Gather documents.
- Submit them to the insurance company.
Second Step: You have to wait for primary source validation and clarification. Provide additional documents if required.
Final Step: If you are enrolled, discuss the billing process with the insurance provider.
Common Credentialing mistakes
The process is quite complicated as it requires paperwork and accuracy, deadlines, and legal implications.
Time Management
Provider credentialing is a lengthy and cumbersome task. Credentialing is a procedure of authenticating healthcare providers’ credentials, from their educational degrees to work history and licenses. The complete process can take 45 to 180 days, and in some cases, the process may take three to six months. Healthcare practitioners and practices should initiate and complete the process before approaching the insurance company. If they submit claims without complete credentialing, the chances of denials and revenue loss increase. To save your time and complete your credentialing without hindrances, you can choose a medical billing company to do this process on your behalf.
Plan on time.
First of all, you must know when credentialing is necessary
- Credentialing is required just after your medical graduation when you plan to join a medical group, a hospital, or you are about to start your practice.
- When a Healthcare provider is switching from one medical entity to another.
- Medical groups or businesses hire new practitioners.
- Healthcare providers must complete their credentialing process on time to support their practice or business.
Accuracy
Credentialing is a validation of documents like educational qualifications, degrees, internship certifications, and previous practice details. So, credentialing requires acute care to certify accuracy and completeness.
Three common errors put a question mark on accuracy
Typing errors; Typos occur at the time of data entry, over-looking to recheck the data, misspelling or wrongly entering email addresses or name
Missing Information: Some relevant data is missed unintentionally. Missing relevant data is a common mistake when manually doing the credentialing process.
Improper Documentation: Poor organization of the documents may lead to ambiguity and confusion. Improper documentation may cause rejection of your application,
For example, missing data or a typing error in details can lead to delays and rework. A minor mistake during the submission of credentials can be a reason for rejection, and you have to resubmit the whole documentation again. Identifying the error and rectification is not only time-consuming but also a difficult task. The delay in the credentialing process affects cash inflow and the revenue cycle of the health care practitioner or business.
Application process mistakes
Certain mistakes occur during the application proper. The mistakes may include
Incomplete application: If a part of a portion of a specific part of the application is left blank or there is an absence of relevant attachment. The absence of an experience letter may be interpreted as ambiguity.
Improper Authorization: Lack of signature and attestation is the worst credentialing mistake that causes rejection.
Delay: If your credentialing application is rejected or returned with a query, try to fix the issue at the earliest opportunity. A delay in query solving may create ambiguity and cause unnecessary delays.
Fail to Track the application’s status: if you do not give a proper follow-up to your application, it may cause the process to prolong. If the insurance company is not responding, you can follow up.
Council for Affordable Quality Health care.
CAQH is an organization that keeps a credentialing record of the maximum number of healthcare providers. Insurance companies trust CAQH for healthcare providers’ profiles. To keep your medical practice or business running smoothly, you must keep your profile updated in CAQH.
Provider Enrollment, Chain, and Ownership system
Medicare is a government own and larger US insurance provider. They have many patients insured, and a healthcare provider who has not been credentialed with them will lose a huge opportunity. PECOS is a credentialing system specialized for the care providers who want to be credentialed in Medicare. The website of PECOS has the option to submit the credentialing application electronically. PECOS keeps the record of the healthcare providers’ credentials. The healthcare provider with multiple insurance companies requires their profiles to be updated in the organizations like PECOS and CAQH.
Mistakes in the enrolment process,
Enrollment with insurance companies is correlated with billing. An error in enrolment can cause losses in the revenue cycle. The common mistake in the enrolment process is
Insurance provider’s criteria: Every insurance company has different rules and enrollment protocols. Unable to meet the specific criteria will lead to rejection.
Insurance coverage: You must know which services typically are covered by the specific insurance company.
Queries remain unanswered: If you don’t assign staff for the queries of the insurance company, they remain unanswered and may lead to a loss.
Attain knowledge about the effects of credentialing mistakes.
It is important to know “how a credentialing mistake can affect your revenue cycle”? A piece of erroneous information in credentialing leads to unwanted delays in getting the benefits to practice or processing a claim. Credentialing mistakes can lead to missing the necessary credit points for Quality Healthcare programs. The credentialing mistakes are
- Wrong or delayed planning
- Misinformation or missing information in the credentialing application
- Incomplete or outdated documents
- Attestation or signatures missing
- CAQH profile not updated.
The mistakes mentioned earlier lead to the denial of the credentialing process. You will get multiple rejection emails which will lead to multiple resubmissions. The resubmission process affects a Practitioner’s enrollment time and causes losses in cash inflows.
Last Words: Avoid Cash inflow loss caused by incomplete credentialing.
You can avoid the revenue loss caused by incomplete credentialing by outsourcing the complete process to an experienced medical billing company. Outsourcing the credentialing process helps you to complete this process on time. As the billing professionals have expertise in this field, rejections are also minimized. The only thing you have to notice is to check the experience of the medical billing company with CAQH and PECOS.