Medical billing is one of the most critical aspects of running a healthcare practice efficiently. It directly impacts cash flow,...
- Welcome to One Source Medical Billing
- 888-624-5563
- [email protected]
- 6810 N. State Road 7 Coconut Creek, FL 33073
According to a recent survey, 26% of physicians state that patients can be potentially protected against malpractice and other medical errors with the help of physician credentialing.
Medical or provider credentialing extends beyond the assessment of a provider’s academic achievements, it encompasses a comprehensive evaluation of their experience, clinical skills, and ethical standing.
Credentialing in medical billing is a challenging task, and to make it accountable and steer clear of potential mistakes, here is what you need to know.
To put it in simpler terms, credentialing in medical billing is a process through which healthcare facilities evaluate the eligibility of prospective practitioners.
The process involves validating physicians’ certifications and licenses, confirming their work history and malpractice coverage, and assessing their education and training.
The legal authority of staff selection and overseeing the credentialing process lies with the official board of a hospital.
Not just that, insurance providers and other healthcare facilities also utilize the medical credentialing process to verify healthcare providers including therapists, pharmacists, dentists, nurses, and physicians.
Each time a healthcare provider switches specialties or opens a new practice, they must undergo credentialing. Physician credentialing services ensure that patients receive care from healthcare providers that meet certain standards of professionalism.
So, exactly does provider credentialing work? It involves three stages: credentialing, privileging, and enrollment or contracting.
Many people tend to confuse credentialing with privileging, which is an entirely different process.
While medical billing credentialing is the evaluation of a doctor’s qualifications, privileging done at healthcare facilities and hospitals provides credentialed physicians with the authority to perform specific procedures. For example, a physician granted privilege by the hospital can perform procedures like endoscopy.
Privileging is granted by conducting OPPE (Ongoing Professional Practice Evaluation) and FPPE, which is a more focused evaluation conducted only if there are concerns related to the physician’s practice.
This step comes after credentialing in the provider credentialing process. The third step is contracting in physician medical billing. This entails the involvement of payers and insurance companies.
In this step, physicians apply for participation in health insurance networks. After approval, the physician enters a legal agreement in which specific terms and reimbursement rates are settled, allowing physicians to bill for their services.
If you’re confused about how to get credentialed with insurance companies, here are some steps you can follow:
Appropriate credentials are crucial for providers to perform treatment and get reimbursement. And if a provider has been credentialed, the process does not stop there.
The medical industry is continuously evolving, and to meet certain criteria, providers undergo re-enrollment or re-credentialing every two years or so.
Once the credentials expire, providers receive a letter entailing a re-credentialing deadline. Repetition of the same credentialing process by a medical credentialing specialist ensures that the provider’s skills are up to par.
After knowing what credentialing is in healthcare, you may still be wondering why it’s important.
Let’s dive right into how credentialing is directly linked to healthcare improvement.
Allocating adequate resources to properly credential each provider can be a hassle most organizations are not equipped for. Extremely lengthy credentialing processes are one of the basic causes of provider credentialing mistakes.
With that said, here are some common credentialing mistakes on the provider’s end.
On the other hand, there are also common credentialing mistakes on the staff’s end that can lead to errors.
What are the provider credentialing process steps?
The provider credentialing steps include researching documentation requirements, selecting insurance providers, ensuring the accuracy of the information, completing the CAQH, waiting for the insurer’s approval, follow-up, and re-certification.
What makes credentialing in medical billing essential?
Credentialing in medical billing is essential for numerous reasons, including reduction in medical errors, streamlining the reimbursement process, compliance, maintaining professionalism, and maintaining patients’ confidence in the providers treating them.