Medical Credentialing Companies: What Services Do They Really Offer?

The most popular question that healthcare professionals, clinic owners, and billing agencies who are new to medical credentialing services ask is what medical credentialing companies do. The solutions they offer are not necessarily as obvious as they may appear. 

You need not panic or fear; we will explain to you in a simple form. 

Understanding the Role of Credentialing in Healthcare 

Credentialing takes center stage in healthcare. It dictates the mode of payment of the providers, how they are trusted, and how they remain in compliance. Nevertheless, it may be tedious and perplexing. This is the reason why a large number of practitioners turn to the assistance of credentialing specialists. Credentialing is the act of proving the qualification and eligibility of a healthcare provider. 

It is meant to assist the doctors, nurses, therapists, and other professionals to satisfy the needs of the insurance companies, the government payers, and also the hospital networks. RoC does this by authenticating qualifications like education and training, giving out state licenses, board certification, employment experience, malpractice insurance, and other vital identifications, including NPI and DEA. After the verification of eligibility, providers may make applications to join insurance panels, a process referred to as payer enrollment. 

What Do Medical Credentialing Companies Actually Do? 

The medical credentialing businesses are also referred to as healthcare credentialing agencies or medical enrollment firms. To cope with this complicated process, they conduct the medical credentialing process on your part. They are in charge of paperwork, filling out applications, talking with payers, and following different statuses of enrollment. They provide services that run through the whole process, and nothing goes to waste, and your application is not left behind. 

Key Services Provided by Medical Credentialing Companies 

Payer Enrollment 

One of the most critical services that credentialing companies offer is payer enrollment. This includes the procurement of insurance firms like Aetna, Blue Cross Blue Shield, UnitedHealthcare, Medicare, and Medicaid. Credentialing professionals collect all required documentation, fill in payer-specific applications, hand them in, and proceed with the payers to follow up and see approvals and rejections. Billing insurance requires proper enrollment, and in the absence of it, it will not be possible to be paid to provide your services. 

The CAQH Registration and Management

Another necessary service is CAQH registration and management. Council on Affordable Quality Healthcare maintains an online database that most insurance firms use to check information about the providers. Credentialing firms will help you fill in your CAQH profile to make sure it is correctly maintained and re-attested every 120 days. This is crucial since the obsolete or inaccurate CAQH information can be expensive to process and can even stop the credentialing process. 

Checking of the License and certification

There is also verification of licenses and certifications by credentialing firms. Your state licenses, DEA registrations, as well as board certifications, have to be verified with the issuing sources, but it is not always the case. Such companies also seek confirmation by the boards of licensing and certifying associations, as well as to ensure that all the qualifications are up to date and effective. The step not only addresses the needs of payers but also improves patient safety. 

Continuing Compliance Surveillance

Credentialing is a process that cannot be done once. Insurance payers demand periodic re-credentialing and continued compliance. Here, it is at this point that continuous compliance monitoring will be necessary. Credentialing companies will record the expiration dates of licenses, re-attestation dates at CAQH, expiration dates of documents, and updates on practice data. They keep an online database that is updated regularly to make sure that your practice will be in compliance at all times. 

Re-Credentialing 

The majority of insurance companies demand re-credentialing, and it is available after every two to three years. This is a recertification of the credentialing steps that one has to pass to stay in-network. The credentialing agencies also keep track of these renewal dates, receive the essentials, renew the profiles where the need be, and directly communicate with the insurance companies, thus avoiding the disruption of any services. Failure to meet these deadlines could lead to deactivation, non-payment, or expulsion from the network. 

Medicare and Medicaid Enrollment

Medicare and Medicaid enrollment is not a simple process. It has its procedures and rules. Credentialing companies have gained knowledge in the management of such processes. They have access to PECOS (the online platform of Medicare) and the portals of state Medicaid, so that the applications are completed properly and in time. These are time-consuming applications, which are prone to errors, and this is the reason why an expert should be used to help them be filled out correctly. 

Multi-Provider and Facility Support

Credentialing companies do not just work with individual providers, but also with groups, clinics, and other medical facilities. They provide services such as group NPI registration, facility licensing, enrolling a few providers, and multi-specialty roster management. Such services are quite useful in the case of growing practices or large clinics that keep on recruiting more providers. 

Credentialing Audits and Clean-Up

In other instances, the problems might be in existence before they are reported to the credentialing companies. The information could be incomplete, there could be delays in the application, or even a complete refusal. Such cases are handled by credentialing companies that offer audit and clean-up services. They check your files, fix the mistakes (or deleted information), redraw the required documents, and return the applications with the corrections. Such clean-up can assist a struggling provider to be put back on track. 

Benefits of Outsourcing Credentialing 

The question that may pop up in your mind is whether you could cope with all this all alone. Technically, yes. Nevertheless, credentialing is a labor-intensive process that demands accuracy, dedication, and understanding of the regulatory standards of the payer. Any mistake would cause a lot of postponements or even loss of revenue. This is the reason why it is normally prudent to outsource to the experts. 

There are obvious advantages to outsourcing credentialing. First, it accelerates enrollment. Credentialing companies are familiar with the operation of the payer systems and can foresee the pitfalls. They are also a great way of eliminating mistakes because trained professionals examine every submission. Outsourcing will not only save you time and money but also enable you and your staff to attend to the patients more. It is also easier to comply because an individual makes sure that deadlines are met and the updates are made on time. Most of all, it gives one a sense of assurance that your practice will not be affected by the loss of revenue because of some minor errors in the paperwork or other steps that will be taken. 

What a Credentialing Impacts Revenue and Cash Flow 

The delays in credentialing will have a direct effect on revenue. As an illustration, a provider who attends to 30 patients in a week may not be reimbursed for the visits in case they have not been credentialed. Not every insurer reimburses retrospectively; it does not pay for the services that have already been provided without previous credentialing. Such delays may also create rejection of the claim, long resubmission, and cash flow will be impeded. Application problems can also be avoided early in the process by using credentialing companies, which is a great advantage in risk management. 

Final Thoughts: A Long-Term Partner for Practice Success 

Medical credentialing companies do much more than make applications. They are long-term partners that assist the healthcare providers to remain compliant and organized, as well as profitable. Whether you are incorporating a sole practice, recruiting a team of practitioners, or running a bigger facility, these professionals make things easy. They save your bottom line in terms of establishing CAQH, getting registered with Medicare, or with re-credentialing. 

You may want to outsource the position to another credentialing firm, whether you are starting a new clinic, have several new providers, or just don’t like to do the credentialing work. Through the assistance of the right person, you would not waste time and money and would remain focused on providing high-quality care to your patients. 

FAQs 

1. Are the services of all credentialing companies alike? 

No, these are different. Some specialize in individual providers, while others focus on hospitals, group practices, or billing companies. Never hesitate to request a comprehensive list of the services you will receive. 

2. Does CAQH fall under credentialing services? 

Yes, setting up your CAQH profile, managing it on an ongoing basis, and re-attesting are part of the standard services offered by most credentialing companies. 

3. What is re-credentialing? 

Re-credentialing is the process of renewing your credentials every few years to stay in-network with insurance payers. It involves updating and resubmitting documents. 

4. What is the normal length of credentialing? 

Credentialing generally takes 90-120 days for some insurance companies, and for Medicare, it can take 45-60 days, and for Medicaid takes 60-120 days. Starting the process early can significantly speed things up. 

5. Can credentialing firms handle Medicare and Medicaid enrollment? 

Yes, most well-established credentialing companies possess the management skills to handle PECOS and state Medicaid enrollments.