Keeping Up with the Credentials

When reviewing (or developing) your revenue cycle management plan, don’t overlook the first steps: making sure all your providers are appropriately credentialed with all your payers and associated products. Credentialing and Provider Enrollment are more than just arduous tasks of paperwork; without them, claims aren’t paid. Opportunities to grow your practice and strengthen your revenue cycle depend on a solid credentialing and contracting program.

Here are several key functions that will help your practice receive proper reimbursement from insurers

  1. Payer Product Analysis: Most insurers offer multiple products and these products can change annually, especially Medicare Advantage, Medicaid HMO, and ACA plans. Review your agreement with each payer so you know which products are included. Changes to the covered products can be requested.
  2. Payer Participation (Par vs. Non-Par) Analysis: Verify that all your providers are participating, in-network providers with your contracted payers (and each product for a particular payer). If you have multiple practice locations, verify each location is linked and that your providers are also linked to each respective location.
  3. Payer Re-Credentialing: CAQH profile update and re-attestation; Medicare/Medicaid Revalidation; Timely completion of re-credentialing applications. Let any of these slip through the crack for your providers and you run the risk of having their participating status revoked and claims denied.
  4. Onboarding New Providers: When adding a new provider to your organization, get a jump on this to avoid a severe lag in collections. While most insurers only allow you to start enrollment 60 days prior to an effective/start date, some insurers will allow you to begin enrollment 90 days prior to the start date. So that means start gathering data and preparing applications 120 days before the start date.

Implementing best practices for provider onboarding to reduce your DIE (Days in Enrollment) and expansion of your payer network to minimize Out-of-Network denials will help streamline your operations, becoming more efficient and productive and hopefully profitable.

Guest blog submitted by PracticeWorx.

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