Due to the abundance of local in-network providers, payer panels are frequently closed. There may not be enough patients in the region to support adding another provider to the network.
A key aspect of revenue cycle management is payer enrollment, which deals with the procedures for a provider to join a specific insurance network. Two crucial phases in payer enrollment—credentialing and contracting—can vary depending on the payer.
Credentialing refers to the procedure that takes place when a provider asks to join a payer’s network. The player carefully examines the provider’s credentials after receiving the application to make sure they meet the requirements for credentialing. When the main source verification, also known as credential verification, is complete, the credentialing file is forwarded to the credentialing committee for approval. After approval, the contractual process starts.
After being given the all-clear by the credentialing committee, contracting happens when a provider is offered a contract for network membership. The supplier then carefully reads the agreement, paying close attention to the terms of the contract’s legality, the payment schedule, and any additional participation requirements. If the provider agrees to the conditions of the agreement, they sign it, and we send them a provider number and the effective date. The provider can then begin billing that payer and begin receiving payment for claims submitted while participating in a network.
It may take between 120 and 150 days to complete the enrolling process. When Medz Healthcare collects the required information and completes the applications for all payers, they are submitted to the payer. Each payer committee reviews applications on a different day depending on the payer.
To ensure that the credentialing process proceeds as quickly and smoothly as possible, a provider can take a variety of steps. Having all the necessary paperwork for your application in advance is one of the most important things you can do. Second, don’t wait until the last minute because it will take 120–150 days on average for commercial payer registrations to be finished. If you know when you want to be billed, be careful to plan things out beforehand to ensure that you can accomplish your goals.
Additionally, it is advantageous to maintain an up-to-date CAQH account so that payers may use the accurate information without needing to ask for document revisions, which would delay the process. Knowing the big payers you want to sign up with is also highly beneficial. If you already have a list of possible payers in mind, the enrollment process can move much more quickly. Medz Healthcare will help you find the payers that can be favourable to you as a provider.
Affordability and Quality Healthcare Council (Council for Quality Affordable Healthcare) Provider information such as specialisations, DEAs, licences, education, malpractice, CVs, and legal records is kept in an online database called ProView. It eliminates duplicative paperwork with healthcare organisations that require information about your profession and practises for directory services, certification, claims administration, and other uses. The majority of payers require updated CAQH databases in order to successfully access and validate each applicant’s personal information during the enrollment and contracting processes. You must have a complete and current CAQH in order to begin the credentialing process.
To create an online profile, you need a CAQH ID, login, and password for the CAQH website. To obtain a user account for the Proview system provided by CAQH, you must speak with the business directly. Every step of this process will be handled by Medz Healthcare on your behalf, and they’ll make sure your account is set up, updated, and kept current at all times.
If the payer rejects your application, you as a provider have two options: accept the decision and submit out-of-network claims, or contest the denial. In order to successfully contest the denial, you must create a compelling case that persuades the payer panel that you would be a valuable addition to their network. You can get help from Medz Healthcare in creating a strong defence on your behalf as a provider.
If your application is turned down, one of the traditional ways to help your appeal get re-filed and approved is to speak more than one language, which helps you serve a larger range of patient demographics. You can get help from Medz Healthcare in figuring out how to present yourself as a significant provider so that the payer panel will see the value in including you in their network.
Although the terms re-attestation, re-credentialing, and re-validation are usually used interchangeably, there are slight differences between them.
The personal information of the supplier is updated and verified upon re-attestation. Individual payers as well as CAQH might be required to do this.
When a specific payer requests that a provider rejoin their panel, re-credentialing frequently takes place. Providers are asked if they still see patients through that particular payer and are obliged to specify whether they want to do so. Re-validation is a process that involves government payers, while some private and commercial payers also use the term to describe their re-credentialing process. This is additionally used to confirm that a provider is still attending to patients for that payer and that they wish to continue doing so in order to remain in-network.
Government payers must complete the revalidation process by certain dates in order to avoid penalties. A provider who does not complete this procedure by the deadline will have to start the insurance application process over, which might take up to 150 days.
To view your credentialing progress and action items, connect to the HIPAA-compliant software portal provided by Medz Healthcare. You have access to each application’s current status as well as all correspondence between our credentialing staff and the payers. Notices stating that you can be asked for supporting documentation for your applications by a Medz Healthcare credentialing specialist are also included in the aforementioned portal. Our onboarding staff will walk you through using our private interface during the course of your onboarding process.
We ensure that your company receives the credentials it requires exactly and on time, allowing you to start receiving payments from the payers of your choosing as soon as is practical. In order for you to make the best choice for your practise, our experts analyse the neighbourhood demographics around your clinic location and identify the best payers based on subscriber density.
Every application that is submitted is tracked, and accurate records are maintained. We stay in touch with you throughout the process to provide you with information on the progress of your application. To make sure that deadlines are met and that your credentials are received on time, we continuously follow up with payers.
We fully guarantee the security, confidentiality, and accuracy of your data, so you can rely on us to assist you in avoiding frequent credentialing mistakes that result in denials and underpayments. By using our HIPAA-compliant portal, you may access all changes to your credentialing in real-time at any moment, seven days a week. This makes our process totally transparent. We simplify the credentialing process for you as much as we can so you can focus on providing your patients with high-quality care.