Medical Insurance Credentialing: Everything you need to know to avoid losing money and clients

Accurate and timely acceptance of medical insurance is essential for obtaining payment from insurance companies. It’s complicated, time-consuming, and can cost thousands of dollars if you get it wrong. That’s why it’s important to partner with a medical billing company that has experience and a proven track record of success.

What is Medical Insurance Credentialing?

Insurance companies check that medical providers are legitimate and eligible to be compensated for services rendered. When a particular payer credentials a service provider, they can bill the payer directly and receive compensation.

What types of medical professionals require credentialing?

Every practice you want to bill an insurance company for must be approved. These include hospitals, clinics, doctors, dentists, physical therapists, behavioral health therapists, optometrists, etc. The term “In-network” (inside the network) means that the provider is currently credentialed by a particular insurance company and is eligible to file claims for reimbursement.

How difficult is it to get credentialed?

It is very complex and time-consuming. It usually takes 20 hours or more to apply to a single-payer. Every country has different needs. Specialists may also require unique documents. These variables make it effortless to miss a step, add the wrong document copy, or make a mistake.

Why are credential errors so common?

Even the slightest mistake in the credentialing process results in claims being denied, which means significant delays in the provider’s revenue stream. Timing is important. 

What are the requirements for the credentialing

Providers have 30 to 90 days to submit the claim after the day of service, depending on the state and purpose. Then, the payer has 90 to 120 days to file that claim. If the claim is rejected and resubmitted, the waiting period starts again. But denying a claim does not reset the 90-day clock for payment. Providers may experience timely application problems if they see patients not credentialed adequately by payers. 

Are there other ways providers lose money due to credentialing errors?

Large payers may make up a more significant percentage of a practice’s revenue. If most of your claims are delayed for three months, you may not have enough income to keep the doors open. You may need to stop seeing customers until the problem is resolved. On the other hand, they could not recover the lost revenue due to the expiry of the application period. 

How most credentialing systems do manage?

Medical practices typically hire one person to handle the credentialing process, which involves gathering about 20 different documents, ensuring the data is accurate and submitting them one by one to other payers. This person will ideally be responsible for re-credentialing in subsequent years. But if that person leaves, gets reassigned, or even gets busy and forgets the approval order, organizational knowledge is lost, and the deadline is missed.

So many practices choose to use credentialing software or outsource the tasks to a billing company that provides this service. Outsourcing to a credentialing service such as DENmaar is an easy way to manage the process.

Why an outsourcing dependency task is better than doing the in-house with dedicated software?

Credential programs are expensive, making them out of reach for most small practices. Although users are limited to most of the tracking features, users complain that the software is challenging to locate. For example, you may fail to set it correctly and miss the re-credentialing window.

How have credentials changed since COVID-19?

The pandemic has changed the healthcare landscape, especially in behavioral health. Many new patients sought treatment and demanded that providers accept insurance. Previously, small clinics could only get away with cash services. Suddenly, they had to get credentials to fill a genuine medical need and didn’t know how to do it.

Another significant change in credential requirements was telehealth. Before the pandemic, there were not many methods of providing telehealth services, and therefore no billing processes. Then almost overnight, telehealth became ubiquitous, and its payers imposed new requirements.

In addition, telehealth allowed behavioral health providers to see more patients daily, and it took more time for a provider to do their billing or manage credentials. 

How can clinics lose patients because of credentialing

Let’s say your staff forgot to re-credential, and all your claims are denied. Rehabilitation takes 3 to 4 months. During that time, you have two terrible options. You can look after patients for free until you are credentialed. It causes a massive loss of income. Or you can close your clinic or hospital for a while. You cannot blame them for going elsewhere for treatment. 

Where to get the best insurance credentialing services?

Looking for insurance credentialing services? You’ve come to the right place! Here at DENmaar, we provide the best insurance credentialing services in the business – and at prices that are more than reasonable. Give us a call today!