DENmaar: Streamlining Clinical, Administrative, and Billing Operations for

Medical credentialing is a complex concept to understand. So it is only natural for one to have several questions about it. In this article, we aim to answer some of the most frequently asked questions surrounding the topic, and in the process, help you understand this complicated but fundamental aspect of our medical world even better. 

Table of Contents

• 1. How Exactly Does Medical Credentialing Work?
  • 1.1. What are the Benefits of Medical Credentialing?
  • 1.2. Can a Provider Allowed to Work During the Credentialing Process?
  • 1.3. What Kind of Facilities Need Credentialing?
  • 1.4. What is the NCQA?
  • 1.5. What is TJC?
  • 1.6. What is CMS?
  • 1.7. What Does Primary Source Verification Mean?
  • 1.8. What is the Credentialing Committee?
  • 1.9. How Long Does a Medical Credentialing Process Last?
  • 1.10. How much will Medical Credentialing Cost You?
• 2. What Do I Look for in a Credentialing Service Provider?

So without much further ado, let’s get started. 

  How Exactly Does Medical Credentialing Work?

Medical credentialing is a process undertaken with the main purpose of maintaining high standards of quality expected from the medical industry. The process usually entails the verification of a healthcare provider’s competency with regards to their educational qualifications, work history, certifications, etc. 

A credentialing authority will contact a provider’s university, certification board and licensing agency to verify whether he or she is capable of providing healthcare. Credentialing is considered to be imperative for all types of providers who engage in providing medical assistance to patients. It needs to be conducted at regular intervals to make sure a healthcare organization or provider is complying with regulatory standards and policies set by bodies like the Centers of Medicare and Medicaid Services, The Joint Commission, National Committee for Quality Assurance, etc. 

What are the Benefits of Medical Credentialing?

Medical credentialing has a plethora of benefits in store for all parties involved with the process. Credentialing provides hospital and clinics with the assurance that their hired staff will offer their services at the level of standards expected of them. Insurance companies can keep their costs down by making sure only competent medical professionals pass the credentialing process. 

Practitioners also benefits immensely from credentialing as they can expand their services to more patients with access to different types of health insurance. However, patients stand to benefit the most out of credentialing. They can rest assured on receiving the highest quality of care from the most qualified providers. 

Can a Provider Allowed to Work During the Credentialing Process?

It is recommended for a healthcare provider to halt their services until the entire credentialing process is complete. This guarantees that all patients receive quality care from only those providers who have verified qualification to offer their services. A healthcare organization is putting itself in unnecessary risk by letting non-credentialed individuals work for them.

That being said, there are a few exceptions to the rule. Medical students, for instance, don’t need credentialing as long as their duties to do not cross the scope of their educational program. They typically don’t need to undergo credentialing as they are working under the strict supervision of superior credentialed providers. 

What Kind of Facilities Need Credentialing?

Aside from practitioners, facilities that engage in the act of providing healthcare need credentialing as well. As such, the following services and facilities need to undertake the process to show they comply with the expected standards of care and competence. 

• •     Dialysis
• •     Ambulance
• •     Home Health Services
• •     Hospice Care
• •     Durable Medical Equipment
• •     Independent Diagnostic Testing
• •     IV Home Infusion Therapy
• •     Laboratories
• •     Prosthetics
• •     Orthotics
• •     Lithotripsy
• •     Urgent Care Centers
• •     Radiology

What is the NCQA?

The NCQA, aka The National Commission for Quality Assurance is an independent non-profit organization. Their job is to evaluate the quality of healthcare provided by medical practices and issues credentials based on their findings. The organizations that go to NCQA for credentialing include managed behavioral healthcare organizations, preferred provider organizations, credentials verification organizations, etc.

What is TJC?

The TJC, or the Joint Commission, is an organization tasked with maintaining high standards of healthcare in the United States of America. They conduct surveys that aim to verify the standards of healthcare provided by the hospitals in USA. Organizations like hospitals proactively answer to accrediting surveys hosted by the TJC every three years. 

What is CMS?

The CMS, or The Centers for Medicare and Medicaid Services is a federal agency that serves under the United Stated Department Health and Human Services. It is responsible for performing a number of functions, which include evaluating quality standards of clinical labs and facilities that have been offering care to patients for a long time. The CMS works closely with state governments to administer and monitor Children’s Health Insurance Program, Medicaid, etc. 

What Does Primary Source Verification Mean?

Primary Source Verification basically means that a credentialing authority will directly verify a provider or organization’s credentials from the source of that credential itself. For instance, a CVO will directly contact the university to verify a practitioners education qualifications. This is usually done to avoid fraud. As such, documents from third-party sources are not entertained. 

What is the Credentialing Committee?

Credentialing committee is responsible for overseeing the entire application review process. They have to make sure that the applicants meet the desired set of quality standards. This committee will include doctors with varying specialties, a liaison with the CVO and a chairperson. If you meet the basic requirements of credentialing, you can appeal a committee’s decision. You will receive all the information needed if it is deemed that you have the right to appeal. 

How Long Does a Medical Credentialing Process Last?

The medical credentialing process can be excruciatingly long. It can take anywhere from days to weeks, and sometimes months. Typically, you can expect the credentialing process to take as long as 90 to 120 days. As such, we recommend starting your application process at least 3 months before you begin your duties as a healthcare provider. 

How much will Medical Credentialing Cost You?

The costs for medical credentialing will vary from CVO to CVO, organization to organization and specialty to specialty. Generally speaking, you can expect to pay around three to four hundred dollars for your application fee alone. You can also anticipate partial reimbursements after your credentialing process has been completed successfully. 

You will also incur costs on periodic and re-credentialing as well. However, you can expect to get this done at a discounted rate. 

  What Do I Look for in a Credentialing Service Provider?

Experience and a good reputation are arguably two of the most prominent factors you must consider when looking for a credentialing service provider. Such service providers are usually home to credentialing specialists who possess the resources, insight and experience needed to handle the entire credentialing and re-credentialing process from start to finish in a quick, efficient and hassle-free manner. 

You will find the above qualities demonstrated perfectly by the credentialing specialists’ right here at DENmaar. With years of industry experience, we’ve helped many providers and facilities get credentialed and can do the same for you. 

Reach out to us at 844-727-3627 to learn more about our services. 

Healthcare providers can take these necessary actions for the patients in scheduling appointments.

Patients always look for convenient and flexible access to healthcare, and for many, this means looking for self-care options. In addition, healthcare approaches influence digital experiences in other industries, including hospitality and travel, in many ways.

For example, self-scheduling bypasses common barriers to access, such as working hours and waiting times. In addition, by enabling patients to schedule their services, physicians build commitment, which has been shown to bridge the gap in care.

The experience of digital patient participation has evolved significantly during the Covid-19 pandemic. With asynchronous symptom screening tools that can be deployed with the help of cloud-based platforms like DENmaar, the care experience can start online quickly. Moreover, the patient’s scheduling is particularly strong during the vaccination process.

When the COVID-19 vaccine became available in late 2020, thousands of people were at risk of overwhelming the health system due to the need to vaccinate quickly and efficiently. The automated self-scheduling process reduced the burden on healthcare workers and enabled patients to choose visits for themselves, allowing healthcare workers to focus on other priorities.

According to a study, about 80 percent of patients prefer doctors who offer online scheduling. Also, a 2019 survey found that 70 percent of patients said they would choose providers who would send emails or texts to take preventive or follow-up care.

Healthcare systems need to evaluate their scheduling options to avoid long waiting times and poor patient experiences because it can affect their ability to attract new patients and retain existing patients. Moreover, patients and staff will benefit from investing in better digital solutions, such as scheduling options.

While making scheduling more straightforward and accessible for patients will help fill out calendars, canceling appointments and no-shows can create vacancies at the back-end of the scheduling process. Patients cancel or miss medical visits for various reasons, but good patient participation strategies can help providers move forward and keep up with the scheduling software.

Here are the top four reasons why patients cancel medical visits and what providers can do to address these issues:

1. Anxiety before an appointment due to unknown fears

For many, the fear and apprehension of seeing a doctor can cause visits to be avoided, delayed, or cancelled. Patients fear the bad news, are reprimanded for postponing treatment, and are uncertain about their financial responsibility. Patients may wait for the visit to avoid a blood test or some tests and procedures. Concerns about exposure to Covid-19 have also increased over the past year, resulting in more patients postponing care or cancelling visits.

Helping patients understand what to expect during their visit helps reduce the fear. In addition, offering virtual care services such as video visits and remote patient monitoring is an excellent option for patients in times of global health crisis.

2. Concerns about high financial costs

Out-of-pocket expenses and employer deductions are higher than usual. According to a poll, many say they do not receive the medical care they need because of the cost. Twenty-two percent of those surveyed stopped treating a severe condition because of the cost.

Helping patients understand their financial responsibilities and educating them about payment plans and their financial options can help reduce cancellations. In addition, using automated digital recording and recording software can help medical office staff gather information about early payments on a patient’s journey and help them have a better conversation about financial resources and responsibilities before a visit.

3. No convenient schedule

Studies show that people work longer hours per week. Challenging work schedules, family lifestyles, and personal commitments make it difficult for some to prioritize their health. When the consequences of taking a break from a workday to see a doctor seem more severe than a health problem, it is easier for patients to prioritize meetings and tasks than their scheduled doctor’s visit, especially if they are not seriously ill.

The availability of flexible scheduling options and virtual care can play a role in helping patients prioritize their health, even in their busy schedules. Also, updated integrations in EHR with video conferencing tools can enable seamless and secure digital encounters for patients.

4. Unavailability of appointment

Increased queues and waiting times can significantly affect cancellation rates. Sick patients, frustrated by waiting so long for an appointment, are more likely to have it cancelled and taken care of in an emergency or retail clinic.

Keeping a small percentage of appointments for daily visits and offering virtual care to visually impaired patients make’s it easier for patients to remain loyal to their known providers and reduces the likelihood of intermittent care elsewhere. Automated waiting list software can help medical offices fill out cancelled visits of patients expecting an early visit. Features that allow patients to schedule for several weeks or even months can help keep patients well and promote a good schedule.

Expecting and working with patient barriers can help providers build a system that works for patients and lead to better financial, operational, and clinical outcomes. When appointment scheduling revolves around patient access and convenience, healthcare providers and staff also reap the benefits of efficient processing.

  Who can take care of your patient scheduling?

The DENmaar Scheduler offers several key features that you should look for when analyzing the quality of a patient scheduling system. The DENmaar schedule may be available to operating staff, but they may not have access to the patient’s complete medical information. This feature helps reduce the risk of any privacy and security breaches.

DENmaar Scheduler is a one-click system for adding, removing, or editing visits, thus reducing the possibility of human error.

Since DENmaar scheduler providers have remote access to their patient portal schedule, it is helpful for them to adjust visits or availability as needed.

It is hard to imagine what the healthcare scene would be like without medical insurance. Medical insurance is, after all, responsible for making health care services accessible to people from all walks of life. That being said, the process that entails claiming insurance and reimbursements can be incredibly frustrating and tedious to undertake with frequent claim denials being a major issue that healthcare organizations and providers face today. 

A claim is said to be denied when a health insurance company refuses to pay the submitted claim. Frequent claims denials can affect the financial health of your healthcare organization. We’ve seen practices dissolve because of decreased revenue triggered by high rates of rejected claims. 

So it is imperative for a healthcare provider or practice to know how to handle claims. This is precisely what we will be focusing on in this article. 

So without much further ado, let’s understand what cause claim denials and how you can avoid or manage them to maximize your reimbursements. 

  Common Reasons for Claim Denials 

The following are some of the most common reasons for claim denials:

• •     Missing or incorrect information
• •     Issues with provider network
• •     Redundant claim
• •     Inaccurate coding of service
• •     Non covered services
• •     No eligibility verification
• •     Delay in filing claims 
• •     Insufficient medical necessity. 

  Preventive Measures you Can Take to Reduce Claim Denials

Like we said before, claim denials can diminish a practice’s revenue. Therefore, it is very important to develop a strategic process to identify what may have caused the situation and address it in time to maximize reimbursements. 

As such, we believe the following preventive measures can help your practice accomplish that without a hassle. 

1. Set up a denial management team

Having a dedicated team that is focused on identifying and resolving claim denials is a great way of handling this problem in an efficient manner. The team can be assigned the role of immediately identifying the cause of a denial, finding a solution to the issue and submitting an appeal on time to make sure the practice isn’t missing out on valuable reimbursements. 

Their purpose would be to investigate each cause of a claim denial systematically in a bid to ferret out the root cause. They can then build a process that makes managing claim denials simple in the future. 

2. Identify and Sort the Cause of Denial

We highly recommend identifying the root cause of a claim denial and then sorting them into groups. There could be a variety of reasons for a claim being denied. It could be missing information, incorrect billing details, or simple eligibility issues. Whatever the reason, your practice needs to document them and your staff must be appropriately trained to avoid these mistakes in the future. 

3. Fast Action

It is recommended to not waste time when you get a notice of claim denial. Instead, you should immediately start working on an appeal that you will submit to make the insurance company reverse their decision. The process of re-submission is a complicated one, and as such, should be undertaken as quickly as possible. 

Not submitting an appeal on time will result in your application being rejected for good while your practice suffers massive revenue losses. 

4. Monitor Your Denial Management Process

Keeping a record of the denials you’ve received, when you’ve received them and the measures you took to address them, will ultimately help you monitor your effectiveness in dealing with such situations. You’ll know if your team is capable of handling denials, what area they are lacking in and if training would help decrease further errors. 

We recommend using visual charts to determine the impact of claim denials on your revenue. You should also work hard to device and implement strategies at every fundamental step of your organization’s revenue cycle. 

5. Outsourcing

Finally, if you find the whole process of handling claim denials overwhelming, you can always reach out to DENmaar to handle it for you. DENmaar specializes in end-to-end insurance credentialing, thus helping providers and healthcare organizations get on an insurance company’s panel. We take care of flawless documentation to make sure your submitted claims are clean, compliant, and have little to no chance of being denied. 

If the claims are denied, we will immediately submit an appeal to make sure your organization isn’t losing out on hard-earned revenue. Outsourcing to DENmaar will also alleviate the burden of credentialing off of your staff, thus freeing them up so they can focus on providing better care to your patients. 

  The Bottom Line

All of the preventive measures we discussed above can help your practice avoid the time-consuming and costly denial management process. In fact, you will be able to handle claims more efficiently if you just identify the core reason behind the denial of claims plaguing your practice and use appropriate preventive measures to tackle them once and for all. 

These preventive measures can be:

• •     Including correct patient information and medical records in your application
• •     Filing claims in a timely manner
• •     Staying updated on changes in the insurance claim process
• •     Training your staff in medical billing and coding
• •     Employing a good EMR (electronic medical recording) system to get access to patient information. 
• •     Verify a patient’s eligibility and insurance before rendering service
• •     Monitor your revenue generation cycle regularly. 

  Need help with claim denials? Contact us at DENmaar now for expert advice and assistance.