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Avoid credentialing pitfalls by Michelle McFarlane R.N., M.S.N., M.B.A.

A 15-year industry veteran shares the secrets

Basically, credentialing refers to the processes involved in getting a physician approved by hospitals and health plans. Approval is granted after reviewing and verifying a physician’s credentials. During the primary source verification process, for example, the hospital and/or health plan obtains original proof of a physician’s education, training, licensure, Board certification, and reported malpractice claims. However, the credentialing process is far from a slam dunk. Every state, every hospital, and every insurance company maintains different rules, forms, processes and requirements for medical credentialing. So how do you maneuver through this bureaucratic nightmare easily, quickly, and most importantly, without it costing you unpaid claims?

You need to follow a few crucial guidelines that can save you money, time, and a lot of frustration. If you learn how credentialing works, you can avoid those nasty snags and re-direct your efforts to more productive projects.

Hospital credentialing


The credentialing work in hospitals involves granting privileges for the physician to practice at the hospital. Unless employed by the hospital (hospitalist or house physician), the hospital does not pay the physician. Instead, the physician treats admitted patients and, when applicable, performs surgery or procedures. Then the physician submits the claims to the insurer/health plan for the services provided to the patient while in the hospital.

The hospital Credentials Committee reviews the physician’s credentials and experience, including:
• Education
• Training
• License(s)
• DEA
• CDS (if applicable)
• Board certification
• Insurance coverage
• Work history
• Medicare/ Medicaid sanctions
• Malpractice claims history
In addition, applicants must submit proof of their experience in procedures, surgeries and other privileges for which they have applied. Once approved, the Committee appoints the physician to the medical staff for one year on the initial appointment and every two years thereafter.

Insurer and health plan credentialing


Know the credentialing requirements. Like hospitals, the insurers verify several background items when credentialing physicians for their networks, including:
• Education
• Training
• License(s)
• DEA
• CDS (if applicable)
• Board certification
• Insurance coverage
• Work history
• Medicare/ Medicaid sanctions
• Malpractice claims history
The insurer’s Credentialing Committee approves the physician based on the network need and the physician’s credentials. The insurers do not approve privileges in their credentialing processes. However, they do link “types” of claims to the credentials of the physician. For example, a cardiologist would be linked to CPT codes submitted by cardiologists, an Obstetrician linked to CPT codes submitted by obstetricians, etc.

Review fee schedules


It is critical you maintain copies of your contracts (group and/or individual) for each insurer and health plan. These contracts include fee schedules for the CPT codes, criteria for termination, and tons of other information. Next, be sure to review the fee schedules before you sign any contracts. You must be sure the claims payment will cover your costs and keep your practice viable. We recommend you obtain fee schedules for your top 10 to 15 CPT codes before you even start the credentialing process. On occasion, it may be to your advantage to stay out of the network. In this instance, you will need to make this clear to your patients since they will probably incur higher co-pays.

Include all locations where you see patients


After the network’s Credentialing Committee approves an application, the insurer routes the physician information to a data system person who inputs the data for the provider directory, claims payment processing, and more. If your initial credentialing application indicated an office at 201 Main St. in Medium Town, U.S.A., as soon as your office submits a claim for another office at 15 Broadway in Medium Town, those claims will be either denied or paid as out-of-network. This glitch can significantly affect your bottom line.

Initial credentialing must include all locations where you see patients. If you add a location or move a location, you need to update this information with the insurers and health plans prior to submitting claims from the “new” locations. Otherwise, the claims can be denied or paid as out-of-network.

Review denials as a whole


Most practices investigate unpaid/denied claims on a case-by-case basis. Although an important procedure, you should also review the causes of denials on an aggregate basis. If most claim denials result from inactive provider numbers, that issue needs to be resolved before additional claims are submitted. Otherwise, the denials will continue.

In addition, we’ve encountered practices not being paid by the insurer or health plan because they reversed the routing and account numbers for the Electronic Funds Transactions. Without looking at the non-payment issue at the aggregate level, this problem would have just continued with office staff trying to resolve each unpaid and/or denied claim one at a time.

Avoid sending your staff into battle


Although the implementation of National Provider Identification numbers for individuals and groups was intended to make the claim submission and payment process easier, your staff may fight battles on this front every day. Claims submissions, either by paper or electronic means, must follow strict submission guidelines to be paid. Software programs can make the claims submission process easier, but the correct numbers must be placed in all the appropriate fields before submission.

Your staff is routinely negotiating, or more often struggling, with the health plans and insurers about claim payments. They interact with provider relations, the clearinghouses, your software vendor, and the claims payment areas. Usually, this turns into a major finger-pointing fiasco with each of these folks blaming the other for the problem. Make sure you submit accurate information, in the proper fields, the first time.

As you all know, health plans look for any reason not to pay your claims. However, you can control the number of rejected claims because of credentialing errors. Just remember these guidelines:

• Ensure all physicians are listed correctly with the health plans so that claims can be paid timely and accurately.
• Include all locations where each physician sees patients.
• Follow the health plan guidelines for pre-authorizations, referrals, etc.
• Review all your unpaid claims as a whole instead of on a case-by-case basis. You can then determine, and correct, the broader error.
• Work within your practice to resolve filing errors, like wrong provider numbers, wrong group numbers, etc.
• Make sure correct information is entered into the proper filing fields on claim forms.
Health plans may do their best to avoid paying your claims. But, with some knowledge and effort, you can make sure your claims won’t be rejected for credentialing errors.

ABOUT THE AUTHOR

 

Michelle McFarlane, R.N., M.S.N., M.B.A., is the founder and president of AddVal, Inc., Southampton, Penn. She founded the company in 1995, and it now represents more than 5,000 medical professionals. Her 25-year career also includes clinical care and graduate-level teaching. She holds master degrees in nursing and business administration/healthcare and finance. She can be contacted at 215-396-8972 and mmcfarla@addvalinc.com

CODAPEDIA LBCCC MGMA WHARTON HEALTH CARE

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