Why it is important to keep track of your provider credentialing
12/12/2021
Contracting…participation…revalidation
These are the words that may bring a nightmarish flashback to some of you. Credentialing is truly a complicated process. Dealing with tons of enrollment contracts, exclusions, and licensing while also monitoring if your desired panel is still open, has never been an easy task. As a result, some practitioners decide to opt out of all the participation contracts and start treating only out-of-network patients. While this may be a good solution for a short-term improvement of cash flow (non-contracted providers tend to set higher charges for their services), this is not a good strategy in the long run.
Providers who do not participate with insurance payers, or those who are active with a limited number of benefit plans, experience a shortage of patients in the long run. Therefore, it is critical to participate with at least the most popular benefit plans to maintain a good cash flow.
And when it comes to participation, good credentialing is all that you need …
Keeping your provider credentialing in good order arguably influences 50% of your payment flow. Below are the top-5 aspects that support this idea:
I. The more plans you participate with – the more patients visit your office
As it was mentioned above, patients are likely to schedule an appointment with a participating provider. This is largely because few would want to risk getting surprise bills or pay their balance payment responsibility.
II. Having your demographics updated with payers keeps rejections at bay.
Imagine a situation where you have just updated your office address and started indicating it on your claims and medical records without notifying insurance payers about this update. In such case, every new claim for services performed in the new location would not be accepted for processing by insurance payers (rejected). Therefore, no payment would be issued.
III. Enrolling into as many sub-plans as possible ensures a sufficient cash flow.
It is often not enough to participate with a single benefit plan of a certain insurance payer. The wide spectrum of membership plans on the current market requires healthcare providers to enroll with as many of them, as possible to avoid claim denials.
IV. Being in full control of your contracts means that you cannot be “fooled”.
Each enrollment contract includes a unique provider fee schedule, which is a dollar amount that must be paid by insurance for a particular service. Providers may accept or may not accept a certain fee schedule when signing a contract. Moreover, participating providers may always refer to this fee schedule to verify if they are paid fairly for their services. However, many practitioners simply ignore this fact and accept any payment amount without disputes. As a result, a portion of their underpaid claims is increasing exponentially.
V. Extra promotion is always beneficial.
Participating healthcare providers who regularly update their credentialing-related information with payers experience a better patient flow. This is large because many insurances have a participating provider directory, which they share with their members. This provider directory usually functions as a search engine, with patients being able to quickly find a participating provider in their area. Therefore, having valid information in a payer’s provider directory is a good way to attract more patients.
Provider credentialing is an ongoing process. Participating healthcare practitioners must constantly ensure the validity of their contracts and update their demographics when applicable.
WCH Service Bureau offers a sophisticated contracting solution for healthcare providers of any specialty and location. Our Credentialing Assurance feature is an annual maintenance service that ensures that your contracts are in a good order.
Contact us for details!
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