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Physician Credentialing: Worth Getting Right to Get Paid

By Jacob Thomas Subscribe to RSS | February 1st 2012 | Views:

As physicians, despite your reputation for benchmarked medical services, you could be losing out when it comes to realizing medical bills reimbursed fully from respective health insurance carriers. And when you start to analyze that elusive reason responsible for hampering your reimbursements, you would invariably end up discovering ‘Credentialing’ as the chief culprit. Quite 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 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 require to be credentialed from 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 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. And as we stand at an important juncture when health insurance sector is realigning its revenue structure post 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 pre-occupation, relegating the all important medical practice to the second! Here are the series of process that would invariably have to clear for being eligible to 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

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 Provides Effective dates, Fee Schedule details and Group affiliation.

Monitoring Expiry dates for NYS-Registrations, DEAs, and CLIA registrations and also handling re-applications for the same.

Handling Re-Credentialing whenever required

But, because of its inevitability and the incidental benefits that come with a well-documented Credentialing, it is prudent that you outsource from competent and proven medical billing companies that can offer quality services at a more economical cost than it would cost if it done internally. The following overriding advantages should amply justify the efficacy of going for outsourced Credentialing:

Insurance carriers pay better to the physicians who are in par with the insurance

Credentialed physicians are considered as reliable providers and are listed in the ‘preferred physicians group’ from which patients usually select their physicians in order to get maximum benefits and avoid ‘out of the pocket expenses’.

Since physician credentialing involves complete background check on providers’ educational qualifications, professional licenses, experience, fellowship programs, and residence, it helps in controlling the healthcare fraud-related crimes and ensures that only qualified physicians deliver services to patients and thereby improving the quality of healthcare in US

Credentialing offers comprehensive access to the fee schedule, which aids in knowing in advance the exact quantum of medical billing for diverse medical practices rendered.

Credentialing is also an accelerator of strategic clinical networks and market expansion as your practices begin to command unprecedented goodwill in the medical fraternity.

We, – known for offering imperial Credentialing, both as an individual component as well as an integral part of our comprehensive suite for Medical Billing Revenue Cycle Management – should be your preferential choice for “Outsourced Credentialing”.

Jacob Thomas - About Author: is the largest consortium of Medical Billers and Coders in the United States. We offer Medical Billing, medical billing companies, Revenue Cycle Management

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