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credentialing

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Author Topic: credentialing  (Read 4771 times)

pjbriese

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credentialing
« on: August 29, 2009, 05:32:34 PM »
I am just starting a medical Billing company and I have Drs asking about credentialing, where is the best web site to find info on this subject and is there a cost for this?

Pay_My_Claims

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Re: credentialing
« Reply #1 on: August 29, 2009, 10:07:29 PM »
Credentialing
From Wikipedia, the free encyclopedia

Credentialing is the process of establishing the qualifications of licensed professionals, organizational members or organizations, and assessing their background and legitimacy. Many health care institutions and provider networks conduct their own credentialing, generally through a credentialing specialist or electronic service, with review by a medical staff or credentialing committee. It may include granting and reviewing specific clinical privileges, and medical or allied health staff membership.

The process is generally an objective evaluation of a subject's current licensure, training or experience, competence, and ability to provide particular services or perform particular procedures.


pjbriese

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Re: credentialing
« Reply #2 on: August 30, 2009, 01:43:57 AM »
Thank you very much, I know what it is, I was just wondering what resourses to use and if there is a charge for this, I know I can add it as an extra service. Just wondering if they charge to do this. Once again, thanks for the info, very much appreciated.

Steve Verno CMBS, CEMCS

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Re: credentialing
« Reply #3 on: August 30, 2009, 10:55:52 AM »
There is credentialing and provider enrollment.

Credentialing is when a hospital does a thorough backgound check on the doctor to allow the provider to have privileges to see patients within the hospital.

Some insurance companies require the provider to do the same before they allow the provider to treat their member and to pay the claims for those visits. 

Some insurance companuies do this as a means of backdooring a provider to a contract. This allows the insurance company to pay the doctor a reduced fee for services rendered.  Some insurance companies will not pay for claims while the credentialing/enrollment process is taking place.

Medicare and Medicaid require enrollment by the provider.  This is done through the processing of a submitted enrollment packet and could include background checks and fingerprinting. 

Credentialing and enrollment should not be done as an extra service offered by billers inexperienced in contracting, insurance credentialing or enrollment requirements.  There are some professional companies that offer this as their sole service but it is not cheap.  Billers should stick to billing only. 
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Pay_My_Claims

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Re: credentialing
« Reply #4 on: August 30, 2009, 01:28:26 PM »
Thank you very much, I know what it is, I was just wondering what resourses to use and if there is a charge for this, I know I can add it as an extra service. Just wondering if they charge to do this. Once again, thanks for the info, very much appreciated.

Sorry, but your question was where can I find out about it.........lead me to believe you didn't know what credentialing was. I agree with Steve, if you don't comprehend what it is,simply tell your physicians, that you don't currently offer those services. There is a lot that can be done with Billing Services (Practice Management Companies) that are not done by all. There are some that don't do DME/HME or dental billing. Its perfectly acceptable to state you don't offer those services.

Medical Billing Forum

Re: credentialing
« Reply #4 on: August 30, 2009, 01:28:26 PM »

pjbriese

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Re: credentialing
« Reply #5 on: August 30, 2009, 02:40:01 PM »
Thank all of you for input, I agree, Medical Billing is a job just to keep up and scrutinizing to make sure everything is correct. credentialing is not something I plan on getting into now. It is something in the future I would like to offer, but not untill I do all research and very familiar with, thats why I am asking if anyone knows of any good websites about the topic and steps you have to take. Believe me, I don't want to bite off more than I can chew.

PMRNC

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Re: credentialing
« Reply #6 on: August 30, 2009, 03:06:49 PM »
Credentialing is a service you will learn as you go, it's not really anything you can be taught it requires a few years of hands on experience with various managed care companies, learning about fee schedules and different contractual terms used in agreements. Since the insurance companies have different policies, regs, rules, provisions.. it's an ongoing process. Also with Credentialing there are various levels involved, the more experienced you are the higher you can go with the services.

 
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Steve Verno CMBS, CEMCS

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Re: credentialing
« Reply #7 on: September 03, 2009, 09:02:26 AM »
It took me 4 years to get it down pat without making any mistakes.  IT was all I did at the time because it took 100% of my time keeping track of the packets sent to the provider, packets sent to the carriers, backdating effective dates and fighting the insurance companies when they paid at a non-par fee after getting paperwork saying they were now registered and effective with the carrier/provider contract.

The practice hired someone in house to do this but she knew nothing and kept sending the work to me to do. A meeting with the provider ended up with her being terminated because she was specifically hired to do this based on her resume and interviews where she insinuated she knew everything about provider credentialing/enrollment.  It landed me a nice payraise.  I learned you cant do billing and credentialing/enrollment at the same time. 
I'l have a double chubby chuck, a mexicali chilibarb, and two cherry cokes
Left hand Blue, Right Leg Green
You got your peanut butter on my milk chocolate.
Dont cut the blue wire! 
I love spam.

QueenAlicia

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Re: credentialing
« Reply #8 on: February 16, 2011, 05:19:08 PM »
I am bringing this topic back up because I have a recent inquiry.  As far as credentialing are we required to negotiate the contract for the provider? 

Thanks.

PMRNC

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Re: credentialing
« Reply #9 on: February 16, 2011, 05:33:16 PM »
Quote
I am bringing this topic back up because I have a recent inquiry.  As far as credentialing are we required to negotiate the contract for the provider? 

No, you are not required to do so, however I always ask someone who is going to credential if they will be offering FULL credentialing or partial. I believe there are 2 tiers to credentialing to which the 2nd tier requires a bit more experience and I strongly recommend the practice/provider having an attorney to review final contracts.

This is always hard to explain, so bare with me.

With basic credentialing (tier 1):  You are basically gathering the provider's credential's, completing the LOI when needed, and completing applications with follow-up.
With FULL credentialing (tier 2) :  You are actually researching fee schedules, doing all the above with basic credentialing, requesting negotiations, reviewing the contracts and then the most important step.. to finalize the fee schedule negotiations an attorney should be hired BY the practice to review and go over the final negotiations and contracts.

Only some carriers will negotiate and even then they will only negotiate certain fees, certain areas..etc.  It is a bit more tedious and there is a lot more research involved and of course.. a much higher price tag <g> 

To take in a step further, i'm even doing DE-Credentialing which is pretty fun because many of the contracts I'm reviewing were never signed off on or even read.. some of the contracts I'm seeing have a 2-3 year wait to get OUT of the network. I'm also doing provider review's to see if they could pull out of Medicare w/out suffering a loss.   Thank you Obamacare!
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Medical Billing Forum

Re: credentialing
« Reply #9 on: February 16, 2011, 05:33:16 PM »