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Credentialing & Contracting

Credentialing in medical billing is mandatory, and insurers require health practitioners. It is so that health providers can serve insurer’s customers after verifying themselves. Credentialing in medical billing is the process that all healthcare service providers perform to become enlisted with insurance companies. Only trusted, vetted, and verified insurance companies include healthcare providers to serve their customers.

Upon successful credentialing in medical billing, the healthcare provider is part of an insurer’s network of hospitals, care providers, health centers, clinics, or medical centers. After successfully applying and receiving the credential as a listed service provider, a healthcare operator can receive reimbursements. The reimbursements are received from the insurer.

The insurer pays the healthcare operator for the services rendered to their customers by the healthcare operator. The agreement terms between the insurer and healthcare service provider are a contracting or credentialing agreement.

Credentialing in medical billing turnaround times varies because there are several factors involved. Government programs such as Medicare have their provider enrollment, chain, and ownership system (PECOS). The approval of provider enrollment and provider credentialing in medical billing is faster than commercial insurance providers, and Medicare has an average approval time of 41 days. On the other hand, commercial insurance carriers can take anywhere from 60 to 180 days. Therefore, this is a game of waiting, hurrying, and waiting again.

Insurance companies have varying standards and policies for enlisting healthcare service providers. When the government and international regulatory policy changes come into effect, there could be a modification in the credentialing in medical billing requirements. This could warrant another cycle of credentialing by the healthcare service provider.

Healthcare service providers are willing to re-credential after initial credentialing in medical billing exercise to access a wider pool of patients. Given the penetration of insurance providers into the market, most people will be covered very shortly under insurance policies. But re-credentialing without using automation can be expensive considering that healthcare service providers already have administrative overheads.

Some insurance companies treat credentialing quality in medical billing efforts as a precursor to providing contracts. The level of contract, the facilities offered within, and the scope of operational flexibility for the healthcare provider are determined by the process of medical credentialing. Credentialing is an active and trusted source of verification for patients. Many patients do not consult physicians or visit hospitals, not in their insurer’s network.

Healthcare providers always want to expand their reach and be enlisted by several insurance providers. But meeting the insurers’ rigorous set of rubric requirements can be overwhelming. The amount of paperwork involved in credentialing in medical billing is substantial.

For credentialing in medical billing, healthcare operators sometimes need to work with CAQH solutions and PECOS for this purpose. It could involve some training, and some costs could arise associated with it. Therefore the need of the hour is a credentialing in medical billing solution that provides intelligent healthcare automation. The level of automation applied in the solution can streamline the application process.

A credentialing in the medical billing system that is agile and adaptable can complete the application process, reduce errors, suggest improvements, and expedite the process. This will allow the healthcare service provider to become a contractor in the quickest time possible. They can start receiving insurance money or benefits for the services rendered to the insurer’s customers.

Given below are some of the reasons why credentialing in medical billing is important:

Instills Confidence

Credentialing elevates the level of confidence in a healthcare delivery process. Patients are sure of the outcomes and become cooperative. One of the aspects of a physician’s healthcare delivery is medical billing. The other important one is credentialing. Medical billing along with credentialing are both tied to each other. Therefore, it is ideal for credentialing in medical billing software that provides physicians and medical practitioners credentialing services.

Patients rely on credentials, and it instills confidence in them. Some insurance providers have a reputation for very high credentialing standards. So any healthcare practitioner enrolled with such insurance companies is easily trusted by patients. Credentialing has to be done with utmost attention and detail. And here is where credentialing in medical billing software can help.

Patient Trust

As credentialing is stringent, a healthcare provider is trusted. Their qualifications and credentials become valid, and patients can trust the services of these providers. In a world of healthcare scams, under-experienced doctors, and medical facilities providing the wrong diagnoses, it is up to the insurance companies to keep the best and discard the rest. Patients require that their insurance companies have stringent vetting requirements so that only the best healthcare practitioners, nursing homes, clinics, and hospitals are enlisted by them. They rely on the insurance company’s internal processes and fully trust enlisted medical practitioners. A credentialing in the medical billing system can automate the patient trust process.

Prevents Loss of Revenue

Credentialing promptly and ahead of time allows continuity of services, and it does not disrupt services to patients. Thus, there is no loss of opportunity and revenue. Medical offices must have a partnership with insurance carriers. Insurance companies may require periodic records of verifications from healthcare professionals to keep the partnership active. The verification list could change from time to time, and it might require a different set of documentation to be furnished by the medical practitioners.

Failing to provide adequate documentation signals a lack of organization in the medical office. Insurance companies may not have tolerance thresholds for such a lack of compliance. In an outright fashion, they may reject the medical practitioner’s office application. Failure to provide credentialing information could result in the insurance company withholding the funds to be disbursed to the medical office, which could lead to revenue loss.

Hiring Process Efficiency

Recruitment agencies and healthcare chains recruiting medical practitioners can use credentialing as an efficient and effective hiring tool. Medical professional credentialing can also be proof of qualification. The credentialing process verifies the medical practitioner’s qualifications, certifications, licenses, and experiences. After successfully determining the validity and integrity of such data, the medical practitioner will be given a contract from the insurance company.

Medical offices, hospitals, government health centers, and other such medical establishments can use this data to hire medical practitioners. Instead of doing all of the vetting and verification processes, they can simply reuse this data. They can use medical billing credentialing software to perform basic verification and hire a medical practitioner. A credentialing check completes verification of a medical practitioner’s residential history, work experience, license, and educational background. Checking through this data is time-consuming, and it is better to reuse verification processes. So therefore, using medical credentialing software is the best way to achieve this.

Improves Reputation

Credentialing improves the reputation of a healthcare center and its medical practitioners, and it provides a source of reference for patients and their insurers. Patients have access to information, and they are researching healthcare providers. Patients are becoming watchful because of the number of bad diagnoses and poor treatment quality instances across healthcare departments. That is why credentialing is an important tool to win their trust and confidence. Not only that, credentialing improves and elevates a healthcare provider’s reputation.

Medical professionals, therefore, take time and effort to credential themselves with insurance companies. They can manage their online reputation and build effective long-standing relationships with their clients by doing this. Once an insurance company gives a medical practitioner the go-ahead, this professional can treat patients. There is no limit to the number of patients treated and the number of insurance providers covered.

Cost Saving

Credentialing in medical billing is cost-saving. If done ahead of time and using automation, there are no risks involved. Healthcare organizations are finding ways to automate and streamline their processes. With increased competition between hospitals and private medical practitioners, they face several constraints. They have to provide quality service at an ideal price point, substantiate the cost of services, constantly innovate to provide quality healthcare and retain their customers.

Doing paperwork and manual data entry is considered wastage in such a scenario. It is better to use automated healthcare solutions instead, and one that takes away all the manual aspects and makes it completely automated. So that medical practitioners and their staff can focus only on non-mundane, non-repetitive, innovative, and forward-moving tasks.

Increase in Third-Party Reimbursements

Credentialing with multiple insurers increases a medical practitioner’s scope of business. They stand to gain revenue streams from multiple insurers. By credentialing with multiple insurers, a medical practitioner can serve customers of all these insurers. Considering that some insurers have a massive customer base, having a contract with them is worthy. So it is not a surprise that many multi-insurer credentialed medical practitioners transitioned their private service to full-fledged multi-specialty multi-bed clinics to serve the humongous numbers of patients.

Given this potential that credentialing can provide, it is good to use medical billing credentialing software to automate credentialing. Using a suite of solutions from a healthcare services software vendor, a medical practitioner can benefit from the complete ecosystem. The credentialing software component will be part of the whole and provide integrations to several other data sets, all of which can be leveraged in a customized way.

Establishes Professionalism

Credentialing is a way to announce professionalism in service. A credentialed service provider is viewed as professional and therefore trusted. The healthcare sector thrives on professionalism. Healthcare practitioners are required to exercise all levels of professionalism. There have been cases where experienced medical practitioners became complacent and thereby unprofessional, and their callous attitude cost patients their health and the medical offices their reputation and revenue.

Medical billing and credentialing software can assist healthcare delivery chains to credential doctors, verify their licenses, set alerts if there are upcoming license recertification exams, and use tools to scrutinize educational claims. This type of automation is better than traditional credential methods. Additionally, using cloud computing in healthcare and clinical data analysis, the process of medical credentialing can be automated, and a standardized workflow can be set into motion. Medical Credentialing solutions can also come under the wide umbrella of healthcare automation, consisting of several services.

Compensation Prerequisite

Credentialing in medical billing is a process that is mandatory for being compensated. Without credentialing, medical billing is withheld, and sometimes the withheld amount is released much later. Medical billing and credentialing are mandatory processes in almost all countries, and all payments are made through insurance service providers. So, medical practitioners and health facilities have to undergo the medical credentialing process as a requirement to be compensated.

Customized healthcare solutions can be implemented to provide prompt services to healthcare organizations. Such a level of automation will reduce delays in physician credentialing. Healthcare analytics solutions can be used to understand the variances in credentialing requirements. It will provide an insight into specific regulatory, compliance, and credentialing-related laws of a particular jurisdiction. Credentialing and medical billing can be streamlined, customized, and tailored to an organization’s specific needs using customized custom healthcare solutions, healthcare analytics solutions, and integrated health solutions.

Ensures Adequacy

Credentialing ensures that hospitals and medical centers can get their staff credentialed, and it can be done using an automated solution. Healthcare organizations may have not hundreds but thousands of staff. Managing their credentialing is a humongous task, especially if manual intervention and manual data entry are involved. It is not a scalable model either. So a medical billing and credentialing system can automate credentialing of hospital staff, allowing the medical organization to increase its capacity.

Healthcare organizations can use advanced medical credentialing and billing software for this. An integrated approach involving health interoperability principles and clinical informatics systems can provide enough data for automation. Medical credentialing can then be done on thousands of hospital staff in a systemized manner.

Reduces Errors

Credentialing reduces errors if it is done using an automated solution. The solution applies on-the-fly verification and auto-population of data as some of the mechanisms to reduce errors.

A startling statistic shows that medical errors have caused close to 100,000 deaths in the US. Healthcare service providers have a huge responsibility on their hands. One of the first steps to ensure zero data errors is to undergo credentialing. A credentialing process validates the certifications and qualifications of a medical practitioner and determines the safety of the medical practice.

A credential management system can be custom-built for an organization, and it can serve as an automated system to resolve all credentialing requirements. This system can be interoperable with many other systems, and it can integrate other credentialing systems and the healthcare center’s various ERP systems. A credential management system such as this will use data from various sources. One of the benefits of such an approach is that it eliminates data ambiguity and duplicity. The fact that there are multiple channels of verification, and multiple dimensions of the same data, can give rise to recording the true nature of data. This type of automation in healthcare can reduce errors and improve the overall quality of healthcare delivery.

Competitive Advantage

Credentialing in time using an automated solution helps medical practices to be competitive. They can get more patients and serve more patient cases. After researching it, patients who seek healthcare at quality health organizations are also the ones who chose the health organization. Patients are demanding and critical of healthcare delivery and expect nothing but the best. In this situation, even a small lapse can spurn a patient. The patient may verbally advertise the shortcomings of the hospital. Soon this unverified rumor could spread and cause loss of reputation.

One of the ways to tackle this is through credentialing. As the first line of defense, a medical facility can only hire qualified and thoroughly verified healthcare practitioners through credentialing. By doing this, almost all quality issues that could arise in healthcare delivery are nullified simply because the medical establishment is using an automated credentialing solution to hire and onboard medical practitioners.

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