Medical Credentialing Services: Why Bundle It With Billing

One of the processes that I was pretty sure of including in our offerings was medical billing and credentialing services.

This is because, when many of the healthcare professionals started looking for outsourced medical billing services, I was keenly observing their problems. And one problem that many of them ignored was credentialing and privilege. It is generally assumed that this should not be a problem, but typically it takes more than anticipated or expected.

For instance, according to research cited by the American Medical Association, physicians took an average of 112 days from contract acceptance to their start date. This means, your plans to expand your services, accommodate new patients and grow your practices are bound to be delayed at least by three to four months.

On top of that, getting a physician credentialed is only part of the process. What you also need to do along with that is to complete insurance enrollment, verify payer requirements, and ensure your billing team has the necessary information to submit claims appropriately.

And when these responsibilities are managed separately, keeping track of provider enrollment, billing readiness, and payer updates can become another burden that you don’t actually want.

Furthermore, medical credentialing and medical billing are intertwined with each other. You see, while credentialing helps in establishing a provider’s qualifications and insurance network participation, billing helps your practice get reimbursed for the service that you provide.

Here, managing both processes together can help you in maintaining better coordination, identify enrollment-related issues and reduce unnecessary administrative work.

On that note, let’s see how the provider credentialing process works for medical practices and the benefits of bundling medical credentialing with billing services for your practice.

How the Provider Credentialing Process Works

The provider credentialing process starts when a physician joins your practice. The first step in this is to collect their professional information and other supporting documents such as license, NPI, education, work history, malpractice coverage, and DEA registration where applicable.

Moreover, if the provider already has a CAQH profile, you need to ensure that the information there is accurate, updated and attested. Once the application is ready, the credentialing team verifies the provider’s qualifications, licenses, board certifications, and professional history through primary sources.

After that, applicable background checks and exclusions or sanctions screening need to be completed before the application moves to the insurance payer for review and approval.

Here’s how the process generally works:

You see, completing the application was just one part of the process. Your practice not only needs to track payer responses but also enrollment status and applicable effective dates. And when these updates reach your billing team on time, it becomes easier to coordinate providers onboarding with billing readiness rather than managing both responsibilities separately.

Provider Enrollment and Insurance Network Participation

Getting a physician credentialed doesn’t necessarily mean they are ready to bill insurance companies. While healthcare providers credentialing verifies a provider’s qualification, provider enrollment establishes their participation with insurance payers.

Let’s try to understand with an example. When enrolling a new physician, your practice may need to submit their individual and group NPI, Tax Identification Number (TIN), practice locations, and payer-specific documentation. And once the application is reviewed, the payer determines whether the provider can participate in its network.

Moreover, after receiving approval you also need to confirm the provider’s enrollment effective date and applicable payer requirements before billing services. The advantage you get with medical credential services is that these updates are then managed separately. Here your billing team may not always have the information needed to determine whether a provider is ready for in-network billing.

That is why coordinating provider enrollment with medical billing can help you and your practice keep payer approvals, effective dates and billing readiness workflows interconnected.

Why Bundling Medical Credentialing With Billing Makes Sense

When you manage medical credentialing and billing separately, keeping both teams updated can become another administrative responsibility. Now, the problem is not that either team is doing something wrong but the margin of information slipping away and not reaching the right people at the right time can be something that may cause never ending delays.

For instance, your credentialing team may receive an enrollment approval, but when your billing team might still be working with outdated provider information. Similarly, if a payer changes its requirements, the billing team needs to know before submitting claims.

Here, when information is kept separately, managing them and identifying gaps in them becomes even more difficult. That is why bundling medical credentialing with billing services makes more sense than ever.

Furthermore, when both services work together, your credentialing team can communicate enrollment updates, approval status, and effective dates directly to the billing team. Due to this everyone works with consistent provider information and understands what needs attention.

With coordinated workflows you also get better accountability. You can easily identify pending enrollment applications, track billing-related dependencies, and understand where administrative follow-ups are required.

As a result, when information flows between both the teams without unnecessary delays, managing provider onboarding and billing operations becomes a lot easier.

Recredentialing and Keeping Provider Records Current

The toughest part of this process is getting a provider credentialed right every time. This is because your practice needs to ensure that their credentials, insurance information, and payer records remain updated as they continue working with you.

Like medical licenses and board certifications may have expiration dates that require timely renewal. The same goes for your CAQH profile, which needs to be updated whenever there are changes in provider information, and some payers require periodic re-attestation.

So, when a physician changes their practice location, joins another group, or updates their professional information, you need to ensure that the changes are reflected in the appropriate payer records.

You see, these updates may seem like routine administrative work, but overlooking them can create credentialing or enrollment complications.

And when your credentialing and billing teams work together, keeping track of these changes becomes easier. Your credentialing team can communicate upcoming renewals, profile updates, and payer requirements, while your billing team can identify whether any changes will affect their existing workflows.

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