The very first step in ophthalmology and optometry medical and vision billing is to ensure that the provider has credentials and is enrolled by the insurance payers and the council of affordable quality healthcare

On a general basis, the credentialing process of providers takes 60 to 120 days so earlier planning is recommended. Just one mistake in between the credentialing process can end up delaying it and this requires you to begin your process again. 

If the provider is not credentialed or re-credentialed accurately with the insurance company then the payer of insurance is not inclined to reimburse the provider for the rendered services. To make things easier you just need to follow up with insurance payers on a constant basis. This will assure you that the providers are enrolled in the network when the enrollment is open. 

Let’s get into medical billing and credentialing services to let you know about the steps you need to take for the assurance of an efficient credential process. 

What is Provider Credentialing?

Provider credentialing that is also known as medical provider credentialing is the process of verifying and collecting the credentials of a doctor that includes his/her professional background and educational history. Credentialing makes sure that the providers have needed things that are licenses, skills to take care of patients, and respective certificates. 

There is another term within it that is insurance plan credentialing. It is referred to as getting on insurance panels. Credentialing a provider is a challenging and time-consuming task as one size never fits all the approaches. 

The Medicare, DME that is durable medical equipment and Medicaid provider credentialing can simply get done by their provided portals on the website. However, most of the insurance payers have their personal process of credentialing. 

On the other hand, most of the commercial insurance payers needed to re-credential every few years. Mediocre demands to refresh the validation every few years, DMEPOS suppliers need re-validation every three years and some states need Medicaid to get re-credential every year. 

If you are a billing and insurance payer and the provider with the payer is not credentialed then this will end up giving you denied claims. And once your claim is denied by the insurance payer, most of those then set a certain time limit for you to re-submit your claim. Also, the patient has secondary insurance so it means you can get into more issues, the more you wait the more issues you get into. This means that the longer you wait the longer you will be unable to recover the amount from your insurance payer. 

Steps Necessary for Credentialing a Provider:

Here are the steps you need to follow to credential a provider. 

  1. Make a list to gather each and every information you require for the provider credentialing application claim. That information includes professional licenses, history of professional work that is resume or curriculum vitae, certificates, malpractice insurance certificate, practice ownership details, references, background checks, bank statements, and more.

  2. Also, you need to collect the National Provider Identifier NPI of the provider. Alongside, get a federal Tax ID and practice EIN, it is required to match the things mentioned on the provider’s W-9 form.

  3. Get the provider registered with CAQH and get their CAQH ID. Must ensure that CAQH features authorize W-9 and malpractice certification for the provider. Check that the employment dates and education are in the month/year format. Your application will get rejected by CAQH if you do not have valid dates posted. Also, CAQH notifies the provider through email to attest again if the information in the profile is fresh and current. Make sure that you are responding promptly.

  4. If you want to have the original handwritten signature of the provider then confirm it while processing the credentialing request.

  5. Complete and provide a full series of applications with each of the insurance payers.

  6. As you are done with reviewing initial credentialing then always make sure to get a reference number from the insurance payer and get this file in your credentialing tracking records.

  7. Follow-up with the insurance payers on the application of provider’s credential. They are notorious as they do not call back if there is something missing in your application. Throughout your credentialing process, follow-up calls or online communication is recommended.

  8. Make sure that your billing system is updated with the information of the payer. Before signing your credentialing contract with an insurance payer, review the fee schedule. Maybe you need to request a fee schedule and give your payer your top 20 codes of billing.

  9. You should keep copies of all the credentialing applications and contracts you have submitted alongside the credentialing and enrollment letter you got from the insurance payer. 

Final Words:

The best one of all the revenue cycle management partners is a great help for you to simplify the provider credentialing and enrollment process by gathering and reviewing your documentation for determining the participation of providers in the entire health plan. 

A trustworthy and efficient credentialing and enrollment service takes you away from the hassle of submitting and tracking the enrollment and credentialing application according to the insurance plan requirements as they are a lot.