Provider Credentialing

An Important Part of Great Revenue Cycle Managment

     What is typically involved with credentialing/contracting?

Some things will vary depending on your organizational structure and specialty but most of the process revolves around certain key steps.

The first step to take is to open the lines of communication.  In some cases the physician’s office staff and/or the physician will be the first point of contact for the credentialing/contracting associate.  There are a number of documents that are required to have on record in addition to personal information.  Receipt of this information dictates how fast we can begin the rest of the process.

Next, we begin making phone calls to the various payers with whom you desire to become contracted.  These calls allow us to determine the appropriate paperwork to complete and forward to your attention for signature and completion of those sections for which we are unable complete.  There is a select group of payers that utilize CAQH, Council for Affordable Quality Healthcare.  CAQH is an online database to which each physician can and should enroll to store all of their credentials.  This database stores anything from your home address to your hospital privileges.  

Here at Medigistics we realize that credentialing/contracting is a long, paper filled process.  As a healthcare provider it is critical that this process be managed from start to finish to ensure that reimbursement is collected at the highest rate possible.  We understand this and are able to provide this service which will allow you to focus on the patient. 

Internally we use a program created by Symed called OneApp.  This is similar in nature to CAQH as it is a database application that stores information relevant to you and your practice.  The only difference is that OneApp is not accessible by insurance companies.  This software simply makes our lives easier by storing your information in one location.  By having this information at our finger tips, we can complete some forms automatically or view the information as we are completing the form for increased accuracy and timeliness. 

As mentioned previously, credentialing/contracting is a long process.  Once all the necessary forms have been completed, signed, and sent to the respective payers, the wait begins.  On average, payers will process an application or contract in 60 days.  Very few payers may process them more quickly but typically time is not on our side.  All we can ask for is patience and understanding of this lengthy process. 

Once we’ve been able to complete the steps above to get you contracted and participating there is still more to be done.  As part of our service, we bill claims electronically to those payers that accept electronic transmissions as well as receive/retrieve electronic remittances or EOBs.  As you may have guessed, that means more forms.  This EDI (electronic claims) and ERA (electronic remittances or EOBs) enrollment is required and involves RealMed, our claims clearinghouse.  In the long run this part of the enrollment process is worth the wait.  By utilizing electronic processing of claims and EOBs, we are able to decrease the number of charge days in your A/R. 

To continue speaking of electronic transmissions, we also encourage our clients to allow the set-up of EFT, electronic funds transfer.  The EFT enrollment process typically takes 30 days.  The beauty of EFT is that payments made by payers hit your bank account directly and much sooner than they would if a check were to be processed. 

Once the initial credentialing/contracting process has been completed, providers are required to re-credential with payers at certain increments.  The requirement may be every 2, 3 or 5 years depending on the payer.  The re-credentialing is speedier than the initial process and can be completed in a matter of weeks.  In addition to re-credentialing, expiring documents and certifications require us to continue communicating with office staff and/or the physician to gain new copies of updated documents to then forward on to payers to keep your record up-to-date in their systems.