A-Guide-to-Navigating-the-Complexities-of-Provider-Credentialing-and-Enrollment

A Guide to Navigating the Complexities of Provider Credentialing and Enrollment

Provider credentialing and enrollment are some of the most crucial steps for a healthcare practice. These steps are usually done at the start because of high dependency and impact on the practice’s future. When a clinic, hospital, or practice is credentialed, they are clear about proceeding with their training and treatment of patients under governed laws. On the other hand, if a practice is not credentialed, or improperly credentialed, it means they’re not yet recognized as trustworthy and reliable and are not allowed to practice and provide healthcare treatments to the patients.

What Is Provider Credentialing?

Provider credentialing is a regulatory process that involves verifying healthcare practices so that they can be allowed to practice. In healthcare credentialing, organizations and insurance companies verify a practitioner’s eligibility by reviewing their qualifications, experience, certifications, and any other information that helps them stand out as a credible practice in the healthcare industry.

What Is Provider Enrollment?

Provider enrollment, on the other hand, is registering practitioners with insurance companies or payers so that they can get reimbursements for the services rendered. Provider enrollment, however, is not limited to just private insurance companies. Many government programs like Medicaid and Medicare can also reimburse providers for the treatments they offer to their patients.

Importance Of Provider Credentialing And Enrollment

One cannot emphasize enough the importance and benefits of provider credentialing and enrollment. Credentialing process primarily puts you on the list of verified and credible doctors. Not only this is important, but it also boosts your reputation amongst other healthcare providers. People know that you are now known for providing quality patient care. With certified training, education, and experience, you can treat patients more professionally.
Provider enrollement on the other hand, helps you in getting in touch with insurance companies and other payers. This has a direct impact on your revenue generation system. Moreover, it also comes with an opportunity to increase your payer circle. You can add more insurance payers to your list (in other words, they can enroll you into their systems). This also helps you to expand your patient base and ultimately, increase your revenue stream.
Importance Of Provider Credentialing And Enrollment

Complexities In Provider Credentialing And Enrollment

Although the credentialing process sounds relatively easy, most practitioners take it easy and give their minimum efforts to get credentialed and enroll. However, complexities that arise during this process can halt the credentialing procedure. Such complications can cause unnecessary and lengthy delays, if not abrupt denials. It’s important to discuss the common complexities that can arise during your provider enrollment and credentialing process and their solutions to avoid such mishaps altogether.
Complexities In Provider Credentialing And Enrollment

Application Errors

One of the most common, yet most critical issues that arise during the healthcare credentialing process, is practitioner's negligence. Since the whole credentialing process requires complete precision and accuracy, a simple mistake in words, numbers, punctuation, etc. can go a long way and can cause unnecessary delays or denials. Sometimes it’s less of a fault of the provider since the forms required for application are indeed quite lengthy and complicated.

One way to fix consistent errors is to take time to extract data from your forms. Since precision is the ultimate solution, it’s best to dedicate most of the time to double-checking the information you have put/written in the form.

Verification Delays

Delays in verification are inevitable. The whole process usually takes up a lot of time because your payer needs to verify your qualifications, certifications, etc. from different institutions and organizations. However, how much of a delay a payer would take, depends on that payer. Some institutions do not have a rapid response time, which causes huge time gaps, sometimes extending to even days.

Since verification delays are unavoidable, you should best start your provider credentialing process as early as possible. Also, it’s best to keep regular tabs on follow-ups so that you can get timely responses.

Re-Credentialing Hassle

As a practitioner, you may know that credentialing is not a one-time process. It’s a constant, recurring process where you need to re-credential your practice to stay updated. However, the process requires your constant attention to the expiration dates of your certificates, licenses, etc. Most of the time it’s hard to keep track of those things, which makes the whole process a lot more challenging than it seems. Also, it’s important to keep tabs on the dates and update your credentialing regularly to avoid billing problems and other legal consequences.

The best thing you can do in this situation is to manage the records, licenses, and expiration dates via management systems. Management tools and apps also help you to automate tasks by putting digitalized dates on tasks. You will get reminders for when your licenses and certifications are going to expire so that you can take the necessary steps beforehand.

Lack Of Communication

Communication plays a big part in credentialing, enrollment, and verification. Throughout the process, you are supposed to communicate clearly and promptly with your payers, institutions, organization, etc. to make sure there isn’t any hindrance or unnecessary delay in credentialing timeline. Many practices, payers, and organizations overlook the importance of effective communication, leading to delayed responses, and credentialing.

The best solution you can adapt here is to keep your communication strong and clear with others. Keep asking for regular updates and don’t lose any follow-ups so that your payers know you are serious about getting things done as soon as possible. One of the better ways to handle the communication side is to assign a person who handles communication protocols on your behalf.

Not Hiring Experts

When it comes to credentialing, you cannot just risk things by handling things all by yourself. As mentioned above, there are tons of complications during this process, and a lot of details to cover, that too with ultimate precision so that you don’t mess up the process. For a practice that handles both patient care and administrative staff, this is a tough nut to crack.

Smart practices prefer hiring an expert medical credentialing team to help them with this process. Companies like MaxRemind Inc. provide expert credentialing services that help you throughout your whole credentialing procedure. From submitting credentialing applications to carrying on with the follow-ups, and staying with you until you are credentialed, MaxRemind Inc. helps you improve your revenue with an additional layer of authenticity with professional credentialing services. With 20 years of medical field experience, you get experts who handle all the credentialing requirements for you.

Conclusion:

Although the healthcare credentialing process sounds easier than done, many practices struggle to get themselves credentialed by reputable payers. There are many loopholes practices overlook which later causes problems and delays in credentialing timeline. Understanding the potential complexities in credentialing and enrollment processes to avoid them and get credentialed without any hassle. It’s always better to hire an additional helping hand, preferably a team of credentialing experts, to help you through the process so that you can focus on what matters the most to you, i.e. your patient care.

FAQs
What is meant by credentialing in US healthcare?

Provider credentialing is the most important step for US healthcare providers. It is the process of verifying practitioner’s eligibility through their qualifications, licensure, etc.

What is meant by provider enrollment?

Provider enrollment is the actual process of enrolling the practitioner with the insurance companies so that they can be reimbursed for the services they provide.

What does it mean when a provider is credentialed?

It means that the provider is eligible to practice. Their qualifications, licensure, and experiences have been thoroughly checked and verified. And they can perform their practice without any legal issues.

What are the benefits of credentialing?

Healthcare credentialing adds a layer of authenticity and credibility to your practice. It boosts your reputation and helps you get more patients.

What are the provider requirements for credentialing?

Here are some basic credentialing requirements for providers:

  1. Education and Training
  2. Licensure
  3. Continuing Medical Education (CME)
  4. Malpractice Insurance
  5. Background Checks