Medical credentialing is the process by which a medical practice becomes eligible to bill insurance and provide care to a network. Without credentialing, a provider cannot begin to bill for services. Delays in the workflow mean that the care provided by a provider can’t be billed until resolution, which means revenue can’t be collected, and practices often don’t appreciate the impact until it begins to have an impact.
The Timeline Reality Behind Medical Credentialing
Credentialing with federal insurance payers generally takes 30 to 90 days from the start of the application process to enrolment. Private insurance timelines differ per insurance company, with some taking 30 to 45 days and others taking much longer if there are mistakes and/or incorrect forms in the application. Knowing these timeframes can help with practice management.
Medical practices already fall behind on the Medical Credentialing process if they do not start before the new provider begins to see patients. The answer is to begin a medical credentialing application as soon as a provider is hired in order to establish simultaneous tracks for clinical onboarding and payer credentialing so the start of clinical practice is revenue ready.
Common Errors That Stall Medical Credentialing Applications
Incomplete medical credentialing applications with erroneous information is the most common reason for delays. Failure to include license numbers, malpractice data that is out-of-date or inaccurate, the wrong taxonomy code, and a lack of work history all result in payer review requests that create 9-week delays in the medical credentialing approval process. The need for additional information and records adds weeks of waiting for credentialing applications.
Another significant medical credentialing delay is found when CAQH profiles are out of sync. Discrepancies between data from the provider’s CAQH profile and information on applications for payers mean that credentialing specialists must amend the data before applications can be processed. Maintaining up-to-date and accurate CAQH profiles is critical to expedite the medical credentialing process.
Group Versus Individual Enrollment in Medical Credentialing
The medical credentialing process must be tracked for group and individual medical provider enrollments, NPI-2 and NPI-1. Both are needed for most claims processing and an error in either impacts the ability to bill claims accurately. The billing entity is defined by the group enrollment, and the rendering provider’s participation status is defined by individual credentialing.
Practices may not be aware that a part of medical credentialing is contract negotiations. The fee schedule that the provider is paid by a commercial payor is determined during credentialing and contracting. Organizations that do not review fee schedules may end up collecting less pay for every service in which they engage.
Medical Billing: The Revenue Cycle Foundation Every Practice Depends On
The process by which clinics or doctors’ offices transform medical encounters into insurance claims and receive payment from insurance companies and patients is known as medical billing. Medical Billing is a part of any revenue cycle practice, from registration to the posting of final payments. Any breakdown in any of these elements affects the revenue of the practice.
Clean Claims and Their Role in Medical Billing Performance
Clean claims are correctly submitted claims the first time, encoding the right codes, including the necessary patient and payer info, and with adequate documentation. Clean claims are paid more quickly than rejected or denied claims. Health care practices with high rates of clean claims have fewer claims to rework and more claims to collect.
Medical billing practices that do not scrub their claims prior to submission put out a percentage of erroneous claims that are automatically rejected. These claims must be corrected and resent, delaying payment and increasing the collection costs. Such a scrubbing routine prevents most of these errors from going out.
Denial Management as a Driver of Medical Billing Revenue
Encountering errors in diagnosis and procedure coding, lack of provider authorization, patient eligibility, and documentation problems, payers deny claims and each denial represents lost revenue that must be tracked down. Often medical practices that do not have a formal denial management process miss timelines for appeals and timely filing, converting their denials to bad debt.
By categorizing denial reasons, medical billing teams can better understand the issues that are creating them, and then correct those errors in their workflows. When the denial is repeated within a group of claims, there is a systematic problem with the coding, documentation or workflow that will continue to cost the practice money until it is fixed. Patterns based denial management is a key step in raising a reactive medical billing office to the level of an efficient one.
Two Disciplines That Together Define Revenue Cycle Success
The two disciplines that make up sustainable practice revenue streams are medical credentialing and medical billing. Without credentialing, there is no billing. Med Brigade brings skill in order to ensure practices are at peak profitability from the start.