Everything DME providers need to know about Credentialing & Re-Credentialing
If you hire a new physician, nurse, or any other healthcare
practitioner, it is important to update them through the various medical credentialing processes.
Provider credentialing is the process of establishing that these medical
providers have the necessary qualifications for performing their medical services.
Even if a DME provider has been approved by the insurance panels
initially, they need to reapply each time when they change their employers.
This process is known as the re-credentialing process and is a periodic
inspection of ensuring that each DME provider is still qualified and is open to
practicing their service in the given network.
Unfortunately, medical
credentialing and re-credentialing is an expensive and time-consuming
process that can take away a lot of your resources' productivity. To make the
system a little more transparent, the experts of 24/7 Medical Billing Services
have documented a guide to help you with the process of reviewing the six key
steps involved with healthcare provider credentialing.
The Importance of Credentialing
Before we start with the discussion, let us answer the question,
"why credentialing is an important practice in the healthcare
domain?"
Healthcare credentialing, also known as insurance credentialing states that all healthcare facilities must ensure that their DME
providers have the necessary credentials to process the insurance claims. Even
if some of your patients are uninsured or wish to pay from their pockets,
credentialing is an essential element for providing broad access to the
necessary patient care.
For different healthcare providers, the physician credentialing
process is unique. While the process is necessary for the physicians,
credentialing is also important for the:
·
Hospitals and the
healthcare agencies
·
The dentists and the
dental care providers
·
Physical therapists
·
Licensed massage
therapists
·
Psychologists and the
counselors
To continue with Medicare and Medicaid, you have to ensure that
your credentialing department meets with the guidelines provided by the below
mentioned federal agencies:
·
Centers for Medicare and
Medicaid Services (CMS)
·
The Joint Commission on
Accreditation of Healthcare Organizations
Apart from these federal regulations, each state has its
credentialing requirements. Following and understanding these requirements can
help you in reducing your business liability in case of potential incorrect or
malpractice claims.
As mentioned above, credentialing is a tedious time-consuming
process. To ensure all your healthcare practitioners receive their credentials
on time, follow the below-mentioned steps:
1. Identify the required
documents
Before you begin with the credentialing process, do remember that
each insurer requires different forms and documentation. You must submit the
completed applications to all the insurers that you plan to work with. Even if
a single piece of information is missing, it can delay the approval by several
weeks or months.
Make a list of all the insurance providers that you plan to work
with. List all the required documents for each of these insurers. These include
but may not be limited to:
·
Name
·
Demographic-related
information such as gender, languages spoken, etc.
·
Social security number
(SSN)
·
Proof of licensure
·
Education and address
information
·
Claim history
·
Specialties
·
Insurance Proof and much
more.
Hopefully, most of this information would be in your records with
the practitioners' resumes and applications. However, you must ensure all this
information is accurate to date.
2. Prioritize the insurers
You must submit multiple applications and thus it can be helpful
if you prioritize which dossiers you would need to submit first.
·
If most of your medical
billing goes to a single insurer, make sure to complete the credentialing with
them at first.
·
Stay updated with the
individual insurers' regulations and compliance. Some insurance companies allow
a streamlined process for the providers who have their credentials updated in
other states. It means quicker approvals.
·
Some insurers provide an
abbreviated application for those providers who are already credentialed with
other states.
Assemble all the applications and the necessary documentation
according to your priority list.
3. Make sure all the
information is accurate and updated
Before applying, you must ensure all the information provided is
accurate and up-to-date. Before the final submission:
·
Carry out the background
check.
·
Verify educational
details, board certification, licensing, and goodwill via healthcare
organizations such as AMA, ECFMG, etc.
·
Review history of
privileges, credentialing, and insurance claims.
·
List any sanctions in
the records of Office
of Inspector General (OIG)
Any form of errors on the submission forms can lead to a lot of
concerns:
·
Make sure that the
months and the dates of the employment are accurately verified by the past
employers. Else it can delay the process of approval.
·
Incorrect phone numbers
or referral contacts can also create unlimited delays or even rejections.
·
Omission of any past
malpractice claims can also disqualify the credentialing process altogether.
Once all the documents are assembled and verified, you must
present them to the management of your facility. They will determine the
specific privileges that they will grant to the new healthcare provider. It is
thus very vital information for the credentialing procedure and you must not
miss it.
Manual verification vs.
other methods
Should you manually verify all the provider information or use any
other alternative verification process?
Some healthcare facilities choose to undergo the credentialing
process in an old-fashioned manner by calling and emailing the various
reference medical schools, the American Medical Association, and other key
associations for the verification of the information found on the resume of the
practitioner.
However, this process is rather time-consuming and can result in
further delays.
Other options include:
Credentialing software: There are some software programs available like the Ready Doc and
the Modio that automates some of the credentialing processes by cross-referencing
the application and the resume information with the AMA profiles and the OIG
and other medical schools.
Outsourcing: Are you feeling overwhelmed with the credentialing process? Outsourcing an offshore credentialing
service can save you tons of time and money.
Once you are certain about the accuracy of the information
provided, you can move on to the next step.
4. Completing the CAQH
Many major healthcare insurers require their partner facilities to
apply for the credentialing via the Council for Affordable Quality Healthcare
(while also looking for their applications).
·
Once you have applied
with an insurer, they will provide you with a CAQH number and also an
invitation to apply.
·
You will also be given
the option to complete the CAQH form online or on paper. The form is around 50
pages long and is most efficiently completed by a computer (since the CAQH will
have to enter the data manually if it is done on paper).
·
CAQH applications can
get significantly delayed with incomplete or inaccurate information.
·
After submitting the
initial application, you must be prepared to re-attest. Re-attestation
maintains the consistency of the insurance eligibility at least four times each year.
5. Wait for verification
Once the application is submitted to the insurer, you have nothing
else to do but wait for their approval. It can be a rather lengthy process.
While most credentialing can be done within 90 days, experts
suggest that you give yourself 150 days. In case of serious differences,
credentialing can take even longer.
6. Follow up
If you do not hear from an insurer, it is important to follow up
with them consistently as it can be the key to a timely approval. You can
ensure it by:
·
Fostering a relationship
with key personnel of the insurance company. Establish a rapport with the
leadership and other staff members to ensure that the applications make their
way to their tables on time.
·
Checking over a call
instead of emailing to maximize the chances of a response.
·
In case more information
is required, compile and verify all the documents timely and submit them.
7. Re-certification
Eventually, your provider will receive their credentialing for the
insurance panel. But it certainly doesn't mean they will remain credentialed
forever.
Credentialing is an ongoing process that requires constant
updating and effort.
·
In case of an error in
an employee's information, do notify the insurers. If they notice any erroneous
information before you submit a correction, it could make way for the
revocation.
·
Most providers need to
re-credential every three years.
Credentialing software can help you in managing credentialing
efficiently. Likewise, it should also be able to notify you when it is time to
renew the credentials for a specific employee. Specific insurers should also
send a renewal notice at the lapse of three years. Respond timely to ensure
that your provider can continue his service inpatient care without any
interruptions.
Tired of following it up
with the insurers? Call in for the experts at 24/7 Medical Billing Services
Working with the insurers can take up a significant time of your
resources. Negotiating the payments contracts is also another laborious process
that requires constant attention.
24/7 Medical Billing Services can help. Outsourcing credentialing and
re-credentialing process can free up a lot of
your resources' time for other important tasks because we know the importance
of caring for your patients as that makes more sense.
About 24/7 Medical Billing Services:
We are a medical billing company that offers ‘24/7
Medical Billing Services’ and support physicians, hospitals, medical
institutions and group practices with our end to end medical billing solutions.
We help you earn more revenue with our quick and affordable services. Our
customized Revenue Cycle Management (RCM) solutions allow physicians to attract
additional revenue and reduce administrative burden or losses.
Contact:
24/7 Medical Billing Services
Tel: +1 888-502-0537
Comments
Post a Comment