Physician Credentialing Services waqas khan October 20, 2024

What is Physician Credentialing in Medical Billing?

This is the process of evaluating and verifying the qualifications and background of healthcare professionals to establish if they fulfill the required conditionalities of healthcare organizations and insurance companies. However, this process is complicated and lengthy, requiring numerous documents. Pro Medical Billing Solutions offers top-tier physician credentialling services to help healthcare physicians navigate these challenges and focus on delivering exceptional healthcare results to patients.

Based on years of rich experience in the industry, we are fully familiar with the complexities involved in physician credentialing services. Our medical credentialing experts have a profound familiarity with regulatory bodies and insurance carriers, with established relationships with major healthcare carriers. This deep understanding enables us to seamlessly navigate the physician contracting and credentialing process, ensuring our clients receive outstanding services and results.

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    Contracting And Pricing

    Pro Medical Billing Solutions has the expertise to offer uniquely superior healthcare provider credentialing and contracting. Our credentialing experts efficiently handle the entire contracting process to ensure a seamless experience for your practice. We manage all the responsibilities from beginning to end, including responding to payer requests, completing the credentialing process, and collecting necessary documents.

    We consider it our top-most priority to meet re-credentialing deadlines and assign the project to an extremely competent and dedicated team to track and initiate the re-credentialing process for your process. We cooperate with you to fill out the initial application, conduct background assessments, and ensure timely approval for your providers.

    Medical Credentialing Services We Offer
    Medicare and Medicaid
    Commercial Insurances’
    Provider Enrollment
    Credentialing Services
    NPI Registration (Type I and Type II)
    CAQH Registration and Maintenance
    MCR DMEPOS Enrollment
    Hospital Privileges
    Contract Negotiation
    Revalidation & Re-credentialing
    Reimbursement Issues Audit
    Providers' State License
    DEA Certificate & Renewal
    CLIA Registration
    Our Proven Methodology Simplified Physician Credentialing Process

    Physician credentialing and contracting have a crucial role in any healthcare organization. The Pro Medical Billing Solutions offers you largely streamlined physician credentialing and contracting services that help you grow your practice and increase your patient reach. Our Medical credentialing experts are well-versed in streamlining the enrollment process, saving you both resources and time while boosting your revenue potential.

    24/7 Dedicated Team

    Pro Medical Billing Solutions has a 24/7 dedicated team of professionals for Physician Credentialling to handle credentialing tasks around the clock, ensuring that the process is consistent and can effectively accommodate the needs of healthcare facilities and health providers at any time.

    PECOS and CAQH Registrations

    Our Medical Billing Experts create and update the PECOS and CAQH credentialing portals, ensuring that your information is always up-to-date and accurate. We manage the revalidation and enrollment of healthcare providers who look forward to participating in the Medicare programs. Our first and top priority is to make the credentialing process more and more simplified for healthcare providers across multiple insurance plans. Our experts come with an exceptionally superior vision to smooth line the credentialing procedure for healthcare practitioners across the United States.

    Contracting Issues and Data Integrity

    Maintaining data integrity and addressing contracting issues are some of the crucial components of effective credentialing. Healthcare facilities should ensure compliance with legal requirements, establish clear contractual terms, and execute robust data management practices to support accurate and smooth credentialing processes for healthcare providers. Our team of professionals immediately addresses any issue that arises relating to contracting and through regular audits, we maintain the integrity of your data.

    Follow-ups

    Medical credentialing is an ongoing procedure that requires healthcare providers to meet the regulations, maintain their qualifications, and fulfill the standards of healthcare organizations. Pro Medical Solutions ensures that healthcare practitioners continue to maintain their credentials and meet the required standards to practice medicine.

    Compliance

    Physician credentialing compliance is a crucial component of the healthcare industry to ensure that the healthcare provider possesses the required credentials to participate in the healthcare networks and practice medicines. Compliance in physician credentialing involves abiding by various guidelines, regulations, and best practices. Experienced professionals of our Medical Billing Company have the skills and competency to ensure compliance with the National Committee for Quality Assurance (NCQA) standards and conduct regular training to keep themselves updated and informed with changing regulations and industry standards.

    What Makes Our Medical Credentialing Services So Special?

    Our Medical credentialing specialists have in-depth knowledge of the credentialing process. We have years of work experience with different healthcare organizations and insurance companies and are aware of their standards and regulations. That’s why we can confidently provide you with accurate physician credentialing services.

    We have a largely transparent system that reduces the risk of errors and minimizes delays. Our team expertise and smooth workflow enable us to efficiently handle complex credentialing tasks, immediately getting you credentialed and enabling you to start seeing patients sooner.

    How Our Medical Billing and Credentialing Services Help Healthcare Facilities?
    Rapid Revenue Recovery
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    First-Pass Resolution
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    Denial & Rejection
    0 % - 10%
    Short Turnaround Time
    0 Hours
    Electronic Claim
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    Electronic Payment
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      Here is the list of some of the specialties we are working with healthcare practitioners throughout the United States to efficiently address their credentialing challenges.

      Our team of experts specializes in the following areas, which are known to be the most impactful for improving Medical Billing efficiency and accuracy.

      If you are searching for a reliable Medical Billing Company – You’ve found it – Contact us  today to learn more about our services!

      Physical Therapy Billing Services
      Pediatric Medical Billing Services
      Pain Management Billing Services
      Internal Medicine Billing Services
      Plastic Surgery Billing Services
      Radiation Oncology Billing Services
      Otolaryngology Billing Services
      Dermatology Billing Services
      Ophthalmology Billing Services
      Oncology Billing Services
      Cardiology Billing Services
      Neurosurgery Billing Services
      Chiropractic Billing Services
      Behavioral Health Billing
      Orthopedic Billing Services
      Vascular Surgery Billing Services
      Urology Billing Services
      Radiology Billing Services
      Anesthesiology Billing Services
      General Surgery Billing Services
      Colon and Rectal Billing Services

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      Frequently Asked Questions

      Insurance Credentialing Services include verifying the qualifications and experience of healthcare providers for insurance network inclusion. It involves submitting an application and supporting documents like licenses, certifications, and malpractice insurance.

      Necessary documents vary depending on the insurance plan and the type of healthcare provider. Here is a list of some basic documentation that is usually required. Documents for individuals:

      • Practitioner License(s)
      • Malpractice Insurance (Certificate of Insurance)
      • DEA (federal) and state CDS certificates
      • Board Certification(s)
      • Current driver’s license
      • CLIA Certificate
      • Business License
      • Letter of bank account verification
      • IRS Form W-9

      Insurance Credentialing is a vital step in ensuring that healthcare providers are paid correctly for their services and don’t suffer any financial losses. In order to obtain reimbursement for medical expenses, doctors and other healthcare professionals must provide insurance companies with proper verifications.

      The turnaround time for insurance carriers varies, so there is no single answer to this question. Major Insurance normally takes between 90-120 days to complete the process, while smaller carriers and insurance plans may take longer.

      When providers submit a participation request to a commercial carrier, they need to complete two processes. The first is credentialing, where the carrier verifies all provided credentials and presents them to their committee for approval. After providers are approved by the credentialing committee, they are directed to the contracting process, where their participation is approved, and they are provided their effective date. Company offering medical credentialing services also makes impacts on the duration.

      If any insurance company denies your credentialing application, you have the right to appeal the decision. To file an appeal, you need to submit a letter to the insurance company that clearly and professionally explains why you believe you should be credentialed. In your letter, you should specifically address the reasons why your application was denied and include any additional documentation, such as letters of recommendation from colleagues or patients.

      Once you have submitted your appeal letter, the insurance company will review it and provide a decision. If your appeal is successful, you will be credentialed with the insurance company. However, if your appeal is denied, you may file a complaint with your state’s insurance commissioner.

      Medicare providers must revalidate every 5 years, while DMEPOS suppliers must revalidate every 3 years. Individual providers can use PECOS online or fill out the paper application. Groups or suppliers must complete the mandatory application. Establishing Electronic Funds Transfer is required for group records. Responding to the revalidation letter within 60 days is crucial. Failure to respond in time may result in the termination of billing privileges.

      NPI 1 functions as your personal identification within the healthcare field, similar to a social security number. It remains linked to your professional journey and is exclusively assigned to you as the practitioner delivering services.

      On the other hand, NPI 2 is an identifier for organizations, representing the location where services are provided. It can be associated with the employer’s company name for those working under an agency or with their business name for those in private practice.

      We strongly recommend that businesses with a tax ID obtain an NPI 2. This is essential for establishing contracts with insurance panels at the organizational level, ensuring proper billing and payment for services. This becomes especially important as businesses and teams expand.

      Additionally, certain insurance panels like Medicaid, Medicare, and BCBS require an NPI 2 for credentialing if the business has a tax ID.

      Insurance panels often begin their process by referring to the information in your CAQH profile. When a healthcare provider submits an application on the panel’s website, the application undergoes a thorough review, and during this review, the panel frequently consults your CAQH profile to verify the information you’ve included in your application.

      Medical credentialing services include a procedure to assess a provider’s suitability for inclusion in an insurance network, conducted before their membership. Recredentialing, which is performed periodically, typically every 1-3 years following the initial approval, aims to confirm the accuracy and currency of the provider’s details on the insurance panel.

      Certainly, when you apply for credentialing through our organization, you have the freedom to choose the specific insurance networks you want to be affiliated with, and you can also specify the ones you’d like to exclude. Typically, most doctors working in outpatient settings opt to become credentialed with approximately 7-8 insurance providers. On the other hand, hospital-based physicians often choose a broader range, usually around 10-15 payors, to accommodate patients with various insurance plans who seek treatment within the hospital. In situations where physicians practice in the tri-state area, which denotes a location at the meeting point of three states, such as our physician-owned practice, it is customary to seek medical credentialing services with as many as 25 different insurance networks.

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