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When it comes to insurance credentialing and Contracting, you have to understand that they are two sides of the same coin. Both need to seamlessly go hand in hand for an individual or group practice to get on insurance panels.

In this article, we’ll try to simplify the concepts of both Insurance Contracting and credentialing and find out how the two concepts intertwine with each other.

Insurance Credentialing

Credentialing is a process providers need to mandatorily undertake if they seek to serve clients covered by the federal insurance program. The applying provider needs first to verify his/her professional records to get credentialed.

This includes NPI, CAQH, professional licenses, diplomas, certifications, attestations, references, etc. All of these documents are essential to verify the accuracy and reputation of the concerned provider.

The same process applies if the Individual provider is applying for privileges in a group practice such as hospitals and surgery centers. They will be asked to submit a completed application which would be later sent to the credentialing entities for verification.

They will request the provider’s professional documents which may include National Data Bank records, credit card records, and criminal background searches.

They will also indulge in what is called primary source verification, which basically means verifying the source of the provider’s diplomas and educational certificates. There is no way to avoid this as hospitals are mandatorily required to check the above-mentioned documents to protect their patients from bad actors.

The Entire Credentialing process can be summed up as follows:

• Getting Information in Order
• Filling out the CAQH form
• Contacting Provider Relations
• Submit Application
• Reviewing Contract after Approval

As you can see, Insurance credentialing is a lengthy process. It is advised to seek help from third-party service providers like Denmaar to efficiently carry out the overwhelming process. The entire Insurance Credentialing and Contracting process culminates with the approval of the contract by the insurance company.

Contracting

If credentialing was the process of gathering and submitting information, contracting is the process of submitting the information and obtaining credentialing approval. This is where the provider finally obtains participation on an insurance panel. This means he/she can now take in clients that are covered by the health insurance coverage of that particular company. We often see providers enroll in these plans, only never to renew them again.

It is almost as if they forget that their application with a said insurance panel comes with an expiration date. A lot of time may pass by, and insurers may not review your contract, thus failing to reflect on the provider’s reimbursement rates. This spells a recipe for disaster as it can lead to thousands of dollars lost and payments interrupted.

Denmaar’s Insurance Credentialing and Contracting for Providers

Although time-consuming, there is a reason why credentialing requires such a high level of scrutiny. The affordable care act has raised the standards of such scrutiny to reduce fraud and abuse when it comes to Medicare and Medicaid enrollment.

The same applies to the contract. It is essential to be aware of the information contained in the contract of approval. Attention needs to be paid on when the period of credentialing may expire, to apply for re-credentialing quickly.

Denmaar is a mhBilling company that helps providers with both credentialing and re-credentialing. We offer a fully automated system to our clients that keep them updated in real-time with updates regarding their application. At Denmaar we are not just concerned with verifying your forms. We also ensure you are always in touch with your process to ensure your credentialing process is as smooth as possible.

Let’s understand the process of Oscar Insurance Credentialing

Oscar insurance company is a technology-focused healthcare company that was founded in 2012.
Headquartered in New York City, Oscar provides its services in 9 states across the USA. These 9 states include New York, New Jersey, Ohio, Texas, California, Tennessee, Arizona, Michigan, and Florida.

The company has been popular for using advanced technology to engage with their clients. They use telemedicine; healthcare based technological interfaces, and transparent claims pricing systems.

Oscar began selling insurance the same year the affordable care act exchanges and individual mandates went into effect. In the first year, Oscar managed to secure 16000 members, and it has progressed into even more significant numbers ever since.

As of today, there are at least 25000 members covered under Oscar’s insurance program. They have not only partnered with 3500 nationally ranked doctors, but also work with 20 top health systems in the US.

Hence credentialing with Oscar is crucial if your practice falls under their jurisdiction. This will allow you to tap into a client base that is covered under the Oscar insurance program. So without much further ado, let’s look at the process Oscar Insurance Credentialing for providers.

Oscar Insurance Corporation Provider Credentialing – The Process

1. Pre Application

Before applying, Oscar requires practitioners to submit the necessary information to confirm that the applying practitioner is meeting basic guidelines of insurance credentialing with OSCAR. An Oscar representative is assigned to the practitioner who informs whether the applying party meets all the mandatory guidelines or not.

2. Submit Your Application

Once the practitioner is deemed compliant with Oscar’s guidelines, they send an e-mail containing all the information the provider needs to initiate the process.

If the application information already exists on the CAQH aka Council for Affordable Quality Healthcare, then OSCAR will with the provider’s permission, proceed to access it electronically.

The following information is essential from the provider, depending on :

•   Basic Personal Information
•   Education and Training Information
•   Specialties and Board Certification
•   Malpractice Insurance Information
•   Work History and References
•   Disclosure and Malpractice History

Here are some materials you’ll need:

•  CV or Resume
•  Malpractice or Insurance Policies
•  Drug Enforcement Administration Certificate
•  State Licenses
•  W9’S
•  Various applicable ID numbers

3. Follow Up

Once Oscar Insurance Credentialing receives the application packet, they will start the credentialing process. The entire process will take 45 to 60 days to culminate.

During this time, the provider will receive e-mails regarding:

• Confirmation of Application received
• Request any missing documentation or application information. If any fundamental document or information is found to be absent during the process, Oscar will send a notification, notifying about the closure of that particular application.
• Constant updates about the status of an application, including delays if any.

4. Oscar Approval

If Oscar approves a particular practitioner’s application, the practitioner becomes an in-network provider with OSCAR. Oscar health Insurance Credentialing will updates the provider information in their database within the next 10 business days.

Being an Oscar in-network provider can be a very long and tedious process. The entire process requires at least 90 – 120 days to be completed and approved. There is a lot of paperwork, which makes the whole process quite frustrating for medical practitioners who want to accept clients with medical insurance. That is where the professional assistance of Denmaar comes into play.

With the help of our credentialing experts, we can walk you through the entire process by accomplishing tasks without any complications and hassle so that you can work on other core areas of your medical practice.

You are probably thinking of whether to hire Insurance Credentialing Specialists or undertake the entire process solo if you are an individual or group practice. If you are even remotely aware of the workings of a typical credentialing process, then you know that going solo is probably not a good idea.

The credentialing process is long, and time-consuming, which can interfere with the efficiency of your practice. As medical professionals, that is something you can’t allow to happen. Hence, hiring credentialing specialists for health insurance payments becomes a wise decision.

What is an Insurance Credentialing Specialist?

The primary role of an Insurance credentialing specialist is to work with group, private or other such medical practices. Hence, helping ensure their medical professionals are complying with government credentialing standards. Insurance Credentialing specialists take it upon themselves to verify the legitimacy of medical professionals with regards to their background, work experience, and education.

An Insurance credentialing expert will have an intricately organized database of the training, education, licensing, and experience information. They ensure that the data thus collected from a healthcare professional is complying with staff policies, government laws, and regulations.

Importance of Insurance Credentialing Specialists

Hiring credentialing experts like Denmaar, helps healthcare organizations in a variety of departments including, of course, the process of credentialing itself. We just discussed the role of insurance credentialing specialists with regard to credentialing. Now let’s dive deep to know why they are absolutely essential players to aid providers in the process of credentialing.

Hiring Qualified Healthcare Professionals

Credentialing specialists can help hospitals and medical organizations hire only those professionals that are qualified and meet all of the credentialing standards set by the government. Specialists extensively verify documents to check whether they are compliant with rules and regulations. This helps hospitals and health care enterprises maintain a staff of competent professionals.

Getting In-Network with Insurance Companies

Getting on insurance panels is what credentialing is all about for many providers. They want to serve clients who are covered under a particular or federal insurance program. Without the necessary credentialing requirements, that is not possible, and the practice loses valuable clients. Third-party credentialing specialists like Denmaar, walk you through the entire process without any hassle so that medical practitioners can concentrate on their practice.

Denmaar also helps in speeding up the process with Medicare, Medicaid, and other commercial insurers, allowing you to now see patients faster and get paid for them sooner.

Credentials Management

The entire application process, diligence, and constant follow-ups can be overwhelming for a provider. However, credentialing specialist relieves providers of such a burden. They keep providers up to date on their application and expedite the process that would usually take months to complete.

Most credentialing specialists now use robust softwar9e’s to manage the credentialing process for their clients. We at Denmaar use a fully automated system that inputs all the relevant information from the provider. The system also provides automated updates on upcoming expiration dates to ensure credentialing is done on time, and providers can continue to accept patients.

Why We Need Credentialing Specialists Today

With a significant portion of the nation’s population already covered under a federal or commercial insurance program, credentialing has become vital. Without it, providers will continue to lose clients. On the other hand, we realize that credentialing is a complex process.

Hence Denmaar has a team of credentialing experts ready to deliver on our promise of efficient credentialing services. Our specialists meet the qualifications that any insurance credentialing specialist job description needs.

With our experts and an advanced system, we promise an efficient credentialing process, unlike any other in the market.