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An investment that allows your provider to begin billing and pulling in revenue faster. Provider credentialing is an essential part of making sure your practice gets paid. If a doctor in your practice isn’t credentialed, then insurance carriers will not reimburse them. Insurance carriers do not reimburse medical offices that bill for services or professionals who have not been properly credentialed. Medicaid plan, Medicare, or insurance company, you may not get paid unless out-of-network benefits are available to that patient. Unfortunately, sometimes the actual credentialing process can be time-consuming and frustrating for everyone involved. However, there are a few ways that you can simplify the process while avoiding rejections and saving time. Modern-day credentialing is far more complex and the process is more error-prone. Read on to discover the convoluted, yet crucial, world of medical credentialing. A process that examines and reviews the health care provider's qualifications and career experience including education, medical certification, training, licenses held, and any specialty certificates to determine if clinical privileges to practice in a particular place can be granted. It must be completed upon the hire or enrollment of a new doctor and regularly afterward to abide by the standards set forth by regulatory and accreditation organizations such as the National Committee for Quality Assurance (NCQA) and The Joint Commission (TJC).

Here’s how we do it !

1. Start with a Good Provider Application

  • A good application should collect all the information needed at one time.

2. Verify Information Provided by Providers

Provider Education – Sources: American Medical Association or Medical School Board Certifications – Source: American Board of Medical Specialties Medical License – Sources: State Medical Board or Department of Health NPI – Source: National Plan & Provider Enumeration System Sanctions – State Sources: Medicaid sanction list in provider’s state of practice Federal Sources: System for Award Management and Office of Inspector General DEA Registration – Source: National Technical Information Service Board Certifications – Source: American Board of Medical Specialties In some cases, you may also want to include the provider’s background check, privileges, affiliation history, and peer reference letters. To get information on the provider’s privileges, simply request a delineation of privileges from each of the hospitals where the provider previously had privileges. You can check with hospitals and practices to verify the provider’s self-reported affiliation history.

3. Investigate any Malpractice Claims

It’s best to take the time to investigate any malpractice claims immediately so you know what you’re dealing with. While the presence of any malpractice claims doesn’t mean that the provider shouldn’t be credentialed, it does mean that there should be some additional scrutiny to the provider’s application. You may want to provide a section in applications for physicians to address any malpractice claims so they can explain the situation. Then that information can be compared with the provider’s claims history. However, if malpractice claims information has been omitted from a provider’s application, it should be a red flag to investigate further.

4. Send Applications for Review

Once we’ve thoroughly gone through forms, we send applications in for review.

4. Send Applications for Review

Be sure there’s usually more to credentialing than sending in your forms and then waiting for approval

A) Communication is Essential
B) We ensure Everything is Accurate
C) Tracking with mailed tracking numbers
D) Regular follow-ups We understand you are an Outsourcing Provider Credentialing to Save Time and Money.

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