Starting a Medical Billing Business > Starting Your Own Medical Billing Business

credentialing

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pjbriese:
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:
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.

 

Steve Verno CMBS, CEMCS:
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. 

QueenAlicia:
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:

--- 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? 
--- End quote ---

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!

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