One-Stop Solution For Revenue Cycle Management Services

provider credentialing process

Crucial Steps for Effective Provider Credentialing and Enrollment in 2023

One of the initial stages in Ophthalmic & Optometry medical and optical billing is ensuring that the doctor has an updated CAQH profile (Council for Affordable Quality Healthcare) and been certified and enrolled by healthcare insurance payers.

The provider credentialing procedure might take anywhere from 60 to 120 days in total, so prepare ahead of time. One error during the credentialing procedure can cause a delay, which typically necessitates restarting the procedure.

If the doctor is not legally credentialed / re-credentialed with the insurance provider, the health insurance payer will just not compensate the doctor for the services performed. To make matters even more difficult, one must follow up with health insurance payers on a regular basis to ensure that doctors are enrolled in-network whenever the enrollment is open.

Let’s look at the distinction between provider credentialing & enrollment, as well as the key actions you must follow to guarantee an effective credentialing operation.

What is Healthcare Provider Credentialing?

The method of acquiring and validating (verifying) a physician’s credentials is known as provider credentialing, also known as medical provider credentialing. Healthcare credentialing assures that physicians have the necessary licenses, certificates, and capabilities to effectively treat patients.

While the online portals for Medicare, Durable Medical Equipment, & Medicaid allow for provider credentialing, many health insurers follow their own healthcare credentialing procedures.

Additionally, the majority of commercial health insurance payers need accreditation every few years. Revalidation is required by Medicare every 5 years, by DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, & Supplies) providers every 3 years, and by 1 year for Medicaid in some states.

Claims will be rejected if you charge a health insurance payer for the service if it is not authorized by the payer. Many insurance companies have time restrictions on resubmitting claims after an initial denial. You might encounter even more difficulties if the patient seems to have secondary insurance so the longer you delay, the more probable it is that you won’t be able to collect the whole amount (or just any amount) from the health insurance payer.

CAQH ProView: What is it?

Most healthcare and vision insurance employ the CAQH ProView within their healthcare credentialing procedure, with the exception of Medicare & Medicaid.

CAQH ProView is really a healthcare credentialing tool that enables oculists, optometric physicians, or other healthcare practitioners to submit provider information into a secured centralized database. CAQH collects data on the health provider and makes it accessible to 3rd party payers.

Registration with CAQH ProView is free for providers. But, even before the provider may submit their data into CAQH (Council for Affordable Quality Healthcare) ProView, the insurer must tell CAQH in order for CAQH to ask the healthcare provider to register CAQH in order for CAQH to build, update, & manage their directory data.

What Exactly is Provider Enrollment?

The process of enrolling a provider in a commercial or federal medical insurance so that the provider can indeed be compensated for services delivered to patients is known as provider enrolment. For instance, after successfully enrolling in the health insurance plan, the doctor/provider is regarded as “in-network.”

Crucial Steps for credentialing a Healthcare Provider

  • Make a list of everything you’ll need for healthcare provider credentialing applications, including medical licenses, employment history – curriculum vitae or résumé, certificates, medical malpractice certificates, recommendations, clinic ownership data, W-9, criminal records, bank records, and more.
  • Collect the provider’s NPI – National Provider Identifier, Federal Income tax ID, & Clinic EIN (each must fit the information here on the W-9 application).
  • Acquire the provider’s CAQH ID by registering them with CAQH. Verify that CAQH has an updated W-9 & liability certification for the provider.
  • Ensure that your work as well as graduation dates are listed in the “month/year” format. CAQH may reject your application if you do not include accurate dates.
  • CAQH will send out an email to the health provider every quarter to “re-attest” the info in the portfolio is up to date—always take actions promptly.
  • Specify if you require the provider’s authentic written signature in order to process the healthcare credentialing.
  • Fill out and submit a set of applications to every health insurance payer.
  • Once you’ve completed the basic credentialing check, always obtain a “reference number” first from the health insurance payer & enter it in your healthcare credentialing tracking records.
  • Follow up with health insurance payers on the progress of the provider’s credentialing application—they are known for not returning calls if there is anything missing out from the application. All through the healthcare credentialing operation, keep track of all calls / online discussions.
  • Maintain copies of any healthcare credentialing applications & contracts which you send, and the health insurance payer’s credentialing & enrolment letters.

All You Need Is a Trusted  Provider Credentialing and Enrollment Operation

The finest RCM partner assists you in simplifying the health provider credentialing & enrollment operation by examining and gathering documents to determine the healthcare provider’s involvement in the health plan.

Practolytics, a trusted and effective credentialing & enrollment service provider, saves you from the hassles of filing and tracking healthcare credentialing and enrolment applications depending on current insurance plan standards.

Over the years, we’ve helped multiple healthcare businesses with their credentialing needs, offering them increased time to concentrate on patient care.

Feel free to contact Practolytics, to know more about our medical credentialing operation and how we may help your practice.

To contact Practolytics, call us at: +(803) 932-9624 (or) +(678) 940-8115 or email us at: [email protected]

Importance of Credentialing services-rcm

ALSO READ5 Tips for Mental Practices to Meet Credentialing Standards