The Dos & Don’ts of Medical Credentialing

All right good morning everybody this is Matthew garni from biz Mattox marketing thank you for attending this webinar titled credentialing do's and don'ts or the do's and don'ts of credentialing and going to be a discussion of sort of your process in dealing with insurance companies become an in-network provider so let me get forward with the.

Introductions so we have the executive team the credentialing executive team with edited aim is dong ace Co and we also have Stephanie yat-sen and Brittany m'lila Morales to talk about best practices in credentialing so I'm going to tap the screen over to Brittany and we get started thanks Matt so the first thing I.

Wanted to talk about was what exactly is credentialing so credentialing is the process of insurance networks they go through and check several documents they do a background screening and they basically check to make sure that the provider meets the standards set out by the insurance company so in that process they're going to check several different.

Things the medical license malpractice DEA any schooling information as well as a data bank search credentialing is also done on an individual basis so it's done by person a person per provider and it's also done by state so what is done in California might not or will not transfer over to a different state credentialing is only good for the state.

That it's been completed in there's also two different types of credentialing you have the first type which is called delegated credentialing and delegated is where a large hospital or a large practice typically 250 plus providers or so credential the providers themselves and so they go through the verification process in-house as opposed to direct.

Credentialing where the insurance company does the credentialing themselves so you send off the information to United Healthcare the insurance company in general and they do credentialing directly through them so the next question that we often get is who do you want to credential with so we know that there's a vast network of.

Different insurance companies that you can be in with and sometimes that's hard for providers to narrow down okay I want to be in with these networks so a couple of things that we recommend to do is first to check your competitors so if there's a provider that's doing the same exact thing that you are and they're maybe 10 or 15 minutes away from you.

Check into it they're on that's a good place to start the next place to look at is your local hospitals that specifically any that you were in with so if you have active privileges at a hospital but the hospital is good to look at because it will encompass pretty much everything that's in the area so it's a good place to find a database if.

You will of what potentially you could see the other area to look at is anything that you would get referrals from so if you're a specialist and you have a PCP that you're good friends with or that would refer to find out what they're in so that they can refer a patient over to you and you can see them one of the things that is not listed.

Here but is a good resource as well is to look at some of your large companies so things like Disneyworld or theme parks or large factories a university see what network they're in with and if you're within a good distance from them that's going to be the network that you want to focus on and get in you know put the most effort into getting in with so.

That you can see all of their employees the next question we get is how long does it take and this is not a quick process it does take some time but I wanted to go over some of the types of providers that will take the longest so anybody that's fresh out of school so they are just completing a residency or they're just completing an internship or.

Anything of that nature they've never done any kind of primary practice credentialing the other is if you're moving from one state to another so I mentioned earlier California's credentialing is not good for Oregon or Kentucky or wherever so if you've never practiced in a state you're going to have to go through the process.

All over again the next thing is if you're switching from what we talked about delegated credentialing over to direct credentialing that's going to also take the longest amount of time and so just to kind of reiterate delegated the insurance company gave the process over to the large clinic or the hospital in most cases so the hospital had to do.

This background screening to give you privileges and to allow you to practice in the hospital so the insurance company says ok great that meets our standards so there's no need in us doing it for all of your 200 300 400 providers directly so we'll just take that as good so when that's done when that's terminated off because you've lost.

You've moved from a hospital the insurance company now has no active credentialing on you because somebody else maintained it so that's where you're having to go to what we call direct credentialing where the insurance payer is now going to have to credential you directly so first I'm going to go over some of the do's and then Stephanie.

Will go over some of the don'ts so the first do is obviously you want to start early some time frames can take anywhere from three to six months some payers are going to take anywhere from eight to nine months it just depends on the payer in your location one thing that we do notice a lot of is this time of year so August September the back of the.

Back-to-school time as well as the beginning of the year everybody wants to open a practice and so what happens is everybody calls the insurance company and they start submitting applications and so things that normally take maybe two or three months to complete will will start to take the full three months or they'll take longer anywhere from.

Four to five months so you want to be aware of the time frame in general BlueCross BlueShield and Aetna are as well as any of your Medicare and Medicaid NGOs are typically going to take the longest as well that's regardless of the time of year it's just their process and the timeframes for them but there are some states like.

Texas that are even longer so in Texas they have this unique thing where you cannot enroll with Medicaid until you're enrolled with Medicare so you start the enrollment for Medicare that takes three months and then after that three months you start the enrollment for Medicaid that takes another three months so you're now six months into the process.

And then let's say that you want to get on with an MCO Amerigroup well care or something like that only after you've enrolled with both of those products can you start the process for Amerigroup of stay well and that process you have to be credentialed all over again with them so that can take anywhere from another additional three to six months so in.

Total you're looking at anywhere from six to twelve months to get on to that final MCO so the next thing that you want to make sure is that you maintain all of your documents the first one that the most important one is the CA QH make sure that that's updated that that's current everything is it is correct in there you also want to make sure that.

The DEA and your license and malpractice are good a lot of times what insurance companies will do is if your DEA is scheduled to expire within a couple of weeks and you will be going through the credentialing process the insurance company will say okay let's hold on and so this is updated and then we'll resume our process so if you're within a couple.

Of weeks months timeframe of one of your documents expiring you need to make sure that you're at least starting the process that way you can tell the insurance company hey you know I'll have everything by date X and then you can send everything but can we see this as an issue with malpractice a lot because my practice.

Expires every year so you're DEA and license it doesn't tend to happen that frequently with the other thing that you want to make sure is that your CV is current so a lot of times providers they forget to add on theirs their CV their current and their new practice and they think well I'm not seeing patients here yet but what I always tell them is you.

Still a business you still started the process to created a business and so it needs to go on to your CV and also for the insurance company it's a good point of reference they are going to see okay this is where they're currently practicing at and then they can also just go chronologically from there of where you what your past history was you.

Know checking all of those as well so so I wanted to talk a little bit about what a CA QH is some of you might know but it stands for the Council for affordable quality health care and essentially it's a database that providers can log into and they can put in all of their information anything that you can think of this ask and then insurance companies.

Can easily log in and access and retrieve all of that information so it's a centralized location for providers to put things in and insurances to easily access it now just because you've enrolled with CA QH does not mean that you started any of the credentialing process most payers do not actually none of them you have to let them know that.

You want to start the credentialing process and so most of the time you have to make a phone call fill out a short application a page or two and let them know hey you know I've got a CA QH here's my identification information here's some my date of birth so you can match it the other thing is some payers some of your smaller payers.

They are not going to necessarily use this the way that larger payers do so your larger payers Aetna United Healthcare they will go in and access your CA QH like we talked about previously but your smaller payers they won't have access to it but that doesn't necessarily mean that you can't utilize it there's actually a function.

On here that allows you to go in and print out a standardized form and you can sign off on a couple of pages and send it in to the insurance company most of your insurance payers will accept that because it's a standardized form it's got all the information that you need and it's easy for them to retrieve that information so do number three is.

That you want to know your state regulations sometimes because you are in your okay to practice in a certain state you meet all the requirements doesn't necessarily mean that you're going to meet all of the requirements for credentialing so that's something you need to check on and you also need to know that things vary by state so we.

Have a lot of providers that move from one practice or one state to another and sometimes they get into a little bit of a pickle because they don't realize that okay I didn't need this in California but I do need it for credentialing purposes for another state so I thought we would go through some of those examples and the main one is a nurse.

Practitioner and a supervising physician a lot of states don't require that a nurse practitioner have a supervising physician they can just go in and practice and they're good to go however almost all of our network works with all of these different states do require that a nurse practitioner have a supervising physician that is also in.

Network so the other example is a hospital privileges we have a lot of providers that just because of their scope of practice they don't ever need to admit patients and so they don't have hospital privileges themselves it's tedious that kind of thing so what the insurance company requires is that the provider has either hospital privileges.

Themselves or they can have admitting arrangements from a provider that if something were to happen that provider could easily admit a patient for them in the main thing that we find is it's not just you have to have a supervising physician or you have to have somebody to admit for you those providers also need to be credentialed.

So they don't necessarily need to be listed on your contracts and as a physician on your practice and all of that but they do need to have already gone through the screening process with the insurance company the credentialing process with the insurance company so that the insurance company knows that they're fine and you know they meet all.

Of their standards and regulations so do number four is your there are some fees that are associated with this process the main ones are going to be Medicare and Medicaid I tell any of our mid levels nurse practitioners anything that's not a physician an MD or a do you can expect to see at least a fee here and there Dee Merck is one that will.

Require a fee that's typically somewhere around five hundred and sixty dollars some Medicare enrollments require a fee as well we have some smaller Medicaid's that are a hundred dollars things of that nature and then if you are credentialing for say a surgery center or a facility those prices will go up.

Medicaid enrollments can can go up to five or six seven hundred dollars just for the surgery center and Roma so just be prepared for some of those fees as well so I'm going to pass it over to Stephanie and she's going to go through the don'ts thanks Brittany the don'ts s was credentialing we have the dues but we also have the donts the donts tend to.

Be tedious work that we have to go back over and constantly review and double-check with the insurance carriers see aqh is an excellent tool that I often refer providers to because it keeps providers aligned with their expiration dates and their licenses the our practices it also allows providers to maintain their updated information as.

Far as the mailing address they're paid to address and CA qh also has another portion where it allows providers to set up their EFT for the direct deposit now whenever a provider needs to do a name change an address change tax ID update their NPI information or anything we always have to notify the insurance carriers and one thing about it.

Providers don't often update their information until after the fact so always refer providers first to your maintain your update with your NPI registry because some providers may have moved an address from an address that they haven't practiced in in three years and then when the insurance carriers tend to process their claims they look.

At that information and they also notice that's he or she has not updated their NPI number I had one doctor who was a referring doctor and every time we filed her claims we couldn't what we always wonder why her claims were being denied or rejected or reprocessed by another entity well one day I just happened to go to NPI.

Registry website and I found she was still listed as in Illinois even though she had moved from Illinois over two years ago the insurance company refer to her NPI information so I requested that that position go back update her NPI information was the correct dress the contact information then we had to go back and request all of her claims to be.

Processed so lack of updates affects the revenue which is the money that comes into the practice if insurance companies receive our information we don't just take for granted that everything is going to be okay we have to constantly call we have to constantly call to make sure that the insurance company received it then we have to follow up to make.

Sure that they have processing correctly and that they are clear in what our requests are because we have to understand they're human beings as well and they sometimes make mistakes but we have to make sure that they follow through on the with the request that we made we always request reference numbers when we contact insurance carriers and.

Document the name so if we there's a problem and we have to go back to someone then we know we can reference that person who we spoke with whatever date we spoke of that person along with their reference number I also had a provider one time that we were doing a name change not a name change I'm sorry an address change and the doctor's first.

Name was Danny but there happened to be another doctor within the same state whose name was Daniel and they had the last name so the insurance company instead of picking up the phone and calling or double-checking the information they just eliminated our provider Danny because they thought that was the other providers nickname and.

They rolled that information over to the other provider and to my understanding some of it's been straightened out but it's been almost a year and we're still having to go back and forth with the insurance company trying to get it straight it resulted in claims processing incorrectly patients having claims processed out of network because.

The doctor our doctor that sent the claims in the insurance company did not have that place of service address and that doctors information so it's always important that we continue to follow up because sometimes faxes into pre router to the wrong area or sometimes we may even miss Dow it's sending out effects so it's always.

Best to keep everything on a time line to make sure that you're staying up-to-date on what needs to be done don't number two don't wait to the last minute see aqh i always suggest the providers if you're not going to real test monthly and when I say real tests tests go into your CA QH login make sure all of your.

Information is still the same and then click on the real test button that allows the insurance companies to go in and see the last time that you updated your information so provider is not doing that every month I also recommend that that provider does it every 60 days but CA QH will send the provider and your credential and contact person an.

Email letting them know hey it's time for you to retest we either need this information updated this is about to expire we need an updated w9 or we need your control substance license or whatever they may need so when CA qh sends you the update since use the request letting you know it's time to update and you log in and you go into.

The system if anything is delinquent or deficient it's going to be lit up and read on the last screen so that allows the provider and the credential and department to know that hey this is something we really need to get on top of once we update that information and upload it in the CA qh and the doctor signs off ora test their application.

Then we contact the insurance company to make sure and advise them it's been updated so whatever information they need they can pull from it this is also another time when you're looking at your license renewals never wait till the last minute to renew your license or you renew your last practice or malpractice just because something inspired at the.

End of the month don't wait threes or don't wait three days before the end of the month because the turnaround period from your insurance provider may not be as quickly so then by the time the insurance company reviews your information if we don't have your updated information then it's going to show it's part then your credentialing.

Will come to an halt until the insurance company receives that updated information I always advise people if you're updating your information through your insurance companies always document the day you fax it or the day you submitted it because oftentimes you're going to have to resubmit that information more than.

One time don't number three don't assume you are in network with certain products I always suggest the providers you have to know your product you have to know what you're signing up for and if you're unsure of it always recommend to providers try to get on as much as you can for example I had a nurse practitioner who assumed that because.

She's on Medicare and Medicaid that she would be able to see United Healthcare Community Health Plan patients which is a Medicaid product the problem with that is she's not credentialed with United Healthcare and she was very upset and said I have met I'm a Medicare provider and a Medicaid I don't understand so I had to explain to her United Healthcare.

Owns that product that is but in order for you to see patients yes you have to have a Medicare number and a Medicaid number however you have to be credentialed with United Healthcare and the United healthcare plan within her state is closed they're not accepting any new providers at this time so what I did recommend to her contact the carrier.

And see if they will give you authorization for those visits of those patients that you treat it which may happen or it may not happen but it's always best to know what plans you're on that's why I always recommend to offices as soon as the provider is credential email or give that communication out to your staff advise your staff members of.

The effective date for their providers and their plan type whether they're on the PPO whether they're on the HMO if they're just on the par plan or if they're on the open access or just whatever but you just never take for granted that just because your credential with one entity that it's going to cross over.

Into the other entity don't number for revalidation Andrey credentialing is very important failure to do so can stop your money from coming in and as quickly as your money is cut off unfortunately to get it back to rolling does not does not happen in a rapid manner for instance Medicare publishes the information on their website advising.

Payers advising providers who's up for revalidation also the commercial insurance payers they tend to send out letters in the mail and oftentimes doctors if it's not a check they won't open that mail because they know if their cheques go direct deposit is automatically going into their bank account so if there are so many your.

Practice that is well versed in the credentialing process or the validation process or you receive some information that you don't understand I always recommend to people that you for that information over to someone who can assist you because you know if you're depending on X amount of thousands of dollars to come in per week then all of.

A sudden that stop then you're going to run into problems that's apparent for your practice or making payroll or other responsibilities so I always tell people instead of trying to keep up with everything in your it either get a big wall calendar write it down or put it in Outlook or try another different software that's out there that would.

Allow you to put future dates in there and instead of putting the final date on the calendar I would put 90 days before it's set to happen because that way it allows you enough time to get all your information together to make sure all of the information is current if you have a new doctor that has come into the practice that allows you enough time to.

Get with that doctor and say hey this is what I need and this is why I need this so as soon as you give this to me we can go ahead and start here with this one moment it looks like we have technical difficulty it's got live because not let me go to the next slide there it goes okay so at this point you're probably a.

Little overwhelmed but biz Maddox can help we have a bunch of different services for credentialing services so if you are adding a new provider if you're brand new yourself opening a new clinic if you're changing your location if you're doing some sort of demographic update we also have a yearly maintenance package that goes over in the handles.

Some of the stuff that 70 was talking about that you don't want to forget updating your CA QH tracking and letting you know when different documents are set to expire things of that nature so I think that is it if anybody's got any questions we can go through Thank You Brittany I'm in Stephanie I do have a few questions already for you so I'm.

Going to go ahead and ask them and the first one be how should a provider decide whether they should join an EPO or keep you always suggest the providers you have to become familiar with your patient base whether you're single majority of HMO patients the majority of PPO or EPO but EPO since that's more specialized network I always recommend.

To specialists in primary care physicians to get on EPA's MP pls because if a primary care physician is treating a patient on their product and they need to refer the patient to you you is always best to be on the same plan so I always suggest the providers it's best to be on as much as out they're wonderful and the second.

Question that came in what are my options the panel is closed so if a panel is closed you have a couple of different options the first one is just to call every couple of months the insurance company will typically tell you three to six you can call on a monthly basis that's a little bit more difficult to get into.

The the best option is to have your patients if you have a couple of patients say with the United healthcare that you can't get into the panel because the panels are closed but patients are coming in and telling you you're the only person I've got an open panel and seeing patients you know I need to be seen you typically have to.

Get an authorization to see that patient so what we've done is we have been able to take to the contractor and say look you know this provider is having to have five and six patients that are coming in and they're having to have an authorization every single time and so it shows the insurance company that is it's more cost-effective for them to.

Just go ahead and credentialing contract you as opposed to tying up the line and getting you know approvals every single time so that's the best bet if a panel is closed I mean my third one is how often should I make sure that my information of the carriers is correct or current I always suggest every 30 to 60 days because there can be little.

Things as APO Box changing a suite number a provider has opened up another practice location provider may have moved from their home address or they may have a separate pay to address so so I always suggest recommend every 30 to 60 days and as a provider do you suggest that I seek participation with as many plans as possible and then what are the.

Key things that I should look for with each plan so I think it's best to get in with as many players as possible especially if you're a brand-new practice because you want to be able to see as many patients as possible a lot of providers don't know this or don't realize that if you're in with a network it's essentially free advertising.

Because the insurance company is going to list you on their their network of providers so you're seeing their but it also allows you to establish a client base and then you know later on down the line if you realize okay I'm not seeing a lot of insurance X then you can decide okay do I need to renew my contract so I need to wreak redentor.

With them that sort of thing so in the beginning unless you're adding a physician and you know what insurance is to be on is best to just get in with as many as you can so that you're not you're not missing patients okay and then it looks like that office come in so far if anyone else has a question there's a little chat box in the.

Right-hand side of the GoToMeeting and you can type your questions there okay it doesn't look like any more coming in so um I know Matt will post this webinar up online for everyone to have a copy of and should you guys have any questions please feel free to email sales if it's Madison com all right well thanks everybody for attending and as Christian.

Mentioned these slides will be up on our website within the next few days yeah will also attend MSU and you can check out learn prognosis comm slash webinars to see our future webinars the next one coming up is on August 28th about Macra so stay tuned for that and thank you for attending

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