Importance of Credentialing in Medical Billing Process

Providers cannot underestimate the importance of proper credentialing if they wish to ensure a steady cash flow. They need to respond to credentialing requests by insurance carries in a timely manner and also be prepared with the accurate documentation. If they lack in meeting the requests, it can lead to deactivation and loss of revenue. For instance, if a carrier deactivates a provider, he/she will have to enroll in the program all over again.

Also, it will put claims on hold anywhere between 90-180 days based on the insurance carrier’s processing time.

  • Medicaid requires annual credentialing
  • Medicare requires re-validation every five years
  • Credentialing for new providers takes 60-120 days by Medicare and Medicaid

Credentialing is very important if you want your practice to earn revenue. So whether you are hiring a new physician for your practice or you are starting a new practice, make sure to send the required information to the credentialing staff as soon as possible because backdating is not allowed by some carriers.

You will need certification for individual or practice along with practice ownership breakdown for the credentialing process. Carriers have been asked by the CMS and Affordable Care Act to become stricter in this process in order to prevent fraud in the healthcare industry.

Medical billing and credentialing have a strong connection. If the provider or physician isn’t credentialed with insurance companies, he/she cannot be an approved provider of services. Till this approval isn’t there, medical billing of services cannot be completed. Once the provider is credentialed, he/she can start treating patients in the network and also start sending claims for reimbursement.

Many practices choose to outsource credentialing task to a third party as this process is quite extensive and needs to be done in an accurate manner. Since it is a tedious process, it is better left to professionals.

A reliable billing company will not only increase insurance reimbursement for the practice but also help in streamlining the vexing credentialing process. They work with experts who are qualified to set up and manage files, data input systems that are used during admissions. Billing companies submit credentialing applications seamlessly and also follow-up till the physician or practice’s enrollment hasn’t been processed. So why fret? It is better to take the weight off of your staff’s shoulders and let experts handle credentialing for you.

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