Medical Billing Forum

General Category => General Questions => Topic started by: illenet2 on April 01, 2010, 03:33:09 PM

Title: Credential question
Post by: illenet2 on April 01, 2010, 03:33:09 PM
I am currently doing credentialing for a Physical Therapy Practice that has done only workers comp. cases. They now want to sign up the Physical Therapy Clinic with private insurance companies. The problem is they only want the PT Clinic itself to be credentialed & not the Doctor. I have never done it that way, so I am unsure whether this is possible? All the applications I have received from Ins. Co. seem to want a provider/doctor's name. Can I just use the head Physical Therapist or must I use the doctor? In other words, can I just credential the clinic only & if so, how do I proceed? Thank you, illenet2
Title: Re: Credential question
Post by: Sportsmom on April 04, 2010, 05:38:38 PM
You would need to check with insurances, some may credential only with a doctor and others will credential each PT.  You are not credential under the group then you will need to credential each one and thats a lot more paper work for you.

When I credential I do it for LPC, LCSW and LMFT the insurnces will not always credential the LPC and LMFT because we do not have doctor to review there charts, but they tell me that up front if I ask other wise I do all the paper work and then they sen dme a letter so I always ask first now.

Title: Re: Credential question
Post by: Michele on April 04, 2010, 08:41:06 PM
Most insurance carriers require that a group has at least one (some times more than one) provider when they credential a group.  I'm not sure if they will allow you to credential just the group. I also am not sure why the provider wants you to do it that way but good luck.

Michele
Title: Re: Credential question
Post by: PMRNC on April 05, 2010, 07:38:46 AM
I concur, usually if you are credentialing a group, each one must be credentialed, they are not just going to assume blind faith for each provider.
Title: Re: Credential question
Post by: illenet2 on April 05, 2010, 09:38:53 AM
Thanks guys, your information verified what I believed as well. I need to do some more Insurance calling. illenet2
Title: Re: Credential question
Post by: lgentle on May 05, 2010, 04:31:54 PM
I am real new at this and I would like someone please tell me what Credential is? Is it some type of insurance the need and where do you find the application?
Thank you, lgentle
Title: Re: Credential question
Post by: PMRNC on May 05, 2010, 05:09:55 PM
It's the process a provider/group goes through to join a health plan for participation status.
Title: Re: Credential question
Post by: lgentle on May 05, 2010, 06:39:04 PM
Is this something I need to be filing or does the provider? If I need to fill this out where do I get the forms? lgentle
Title: Re: Credential question
Post by: PMRNC on May 06, 2010, 10:29:15 AM
It's NOT a one form type of thing. Each carrier has their own method of credentialing. If you are doing billing for a client who has existing contracts you should familiarize yourself with them, however I would not undertake the services of credentialing if you do not have experience. There is a process to credentialing and it should not be done unless you know what you are doing. It is the full process (with each carrier) of "credentialing" onto their panel. Contracts, fee schedules, etc are factored into the process.
Title: Re: Credential question
Post by: KimGailey on May 11, 2010, 04:00:33 PM
I found a great website to do credentialing at www.caqh.org

My question is, does a Dr have to complete credentialing with the insurance company to file a claim with them?  If they don't do the credentialing, wouldn't it just be out of network?
Title: Re: Credential question
Post by: ste on May 11, 2010, 07:13:13 PM
I can relate about completing an application and thinking every possible question could have been asked and the insurance or network organization has been thoroughly researched and few weeks after submitting the application the physician gets a brief postcard in the mail saying "we don't credential naturopaths". One does quickly learn to ask the right questions.
Title: Re: Credential question
Post by: Pay_My_Claims on May 11, 2010, 08:41:05 PM
I found a great website to do credentialing at www.caqh.org

My question is, does a Dr have to complete credentialing with the insurance company to file a claim with them?  If they don't do the credentialing, wouldn't it just be out of network?

physicians have to be invited into CaQh
Title: Re: Credential question
Post by: Michele on May 12, 2010, 07:27:35 AM
CAQH isn't really a website to 'do credentialing'.  It is an online universal credentialing application that many insurance carriers utilize to reduce the paperwork required to credential a provider.  Charlene is correct, CAQH is not something a provider can sign up for.  CAQH numbers are only issued by insurance carriers.  CAQH cannot (well they can but they won't) assign CAQH provider numbers to a provider.  CAQH is a wonderful tool, but it doesn't replace credentialing, it just assists.  Each insurance carrier must still be contacted and most still have additional paperwork that must be completed in addition to the CAQH.

Michele
Title: Re: Credential question
Post by: DMK on May 12, 2010, 11:20:09 AM
I'm a little concerned about some of the questions being asked.  It seems like there are some billers out there who are in WAY over their heads.  It makes me wonder if offices are hiring completely inexperienced employees and making them "figure it out".  Hmmmmm.
Title: Re: Credential question
Post by: PMRNC on May 13, 2010, 06:27:11 AM
 ::)
Title: Re: Credential question
Post by: ste on May 14, 2010, 03:06:41 PM
Yes. I'm in way over my head. However, I do expect a level of civility which enables us to encourage one another. Is this a reasonable expectation?
Title: Re: Credential question
Post by: DMK on May 14, 2010, 04:54:16 PM
I apologize if my comment offended you.  It wasn't intentional. I was trying to point out that employers seem to be taking advantage of employees by throwing them to the wolves and expecting them to "figure it out".  It's up to the business owners (providers, clinic owners, etc.) to get credentialed.  They shouldn't expect anyone else, other than a professional credentialer to do this for them.  It's not fair to the employee. 

I'm definitely on your side of this.  Sometimes we have to educate our employers as to what THEY are responsible for.

Again, I'm sorry if I spoke unkindly.  I didn't mean it that way.  My concern is for my fellow billers and processors and keeping them out of hot water.
Title: Re: Credential question
Post by: Pay_My_Claims on May 15, 2010, 07:16:49 AM
I agree with you 100% DMK. As "experts" in this field sometimes we have to show tough love. Yes Providers can have unreasonable expectations of billers. They want them to run the front office, do credentialing, and sometimes be an MA to assist with patient care. A lot of this stems from the decrease in reimbursements, but some just comes from providers wanting to cut corners. On the other hand we do have billers who want to fake it til they make it, creating havoc and destruction on providers revenue. We "the home based billers" hurt because of this. Providers are leery of hiring us because of being burned by others. As much as I need business, I have already fired 2 clients, God blesses me with more knocking at my door!!

@ STE, not sure if you are working for yourself, or if you work for a providers office. If you can admit that you are over your head, you are 1 step better than those who won't. We are in this forum to help you and others with your issues. I can offer you as well as others a bit of advice. Research is key in medical billing. Not 1 expert in here knows it all. There are some that know credentialing, but don't do it. I personally don't like it, but I am currently (may change) offer it for providers. I only like to do it for start up offices however. Keep your questions coming, but also keep researching. Look at the Medicare credentialing form to see how it appears. Look at other payers forms...see if this is something you want to do I can tell you it is very time consuming and tedious work.

Good Blessings to you