Provider credentialing is one of the most important aspects of medical billing. Patients are the ones who decide the future of any healthcare organization. They expect quality services from healthcare providers. The competence of the providers is evaluated with the help of the provider credentialing procedure. Starting from the high school diploma to the latest medical training certification- all papers must be properly documented and verified.

The procedure though vital is extremely cumbersome for the staff members to complete. Many healthcare organizations working with a limited team trust the leading companies to outsource this job. However, provider credentialing involves very intricate steps and sensitive documents that must be handled with care. If you are searching for a good revenue cycle management company to outsource your work, make sure you remember the following checkpoints before zeroing in on one.

1.Experienced in Provider Credentialing:

Not all companies in the revenue management industry are experienced in provider credentialing. The needs of each organization are extremely specific. Make sure that the companies you are searching through have enough domain-specific knowledge in provider credentialing.

2.Trained in Provider Credentialing:

Leading revenue cycle companies offering provider credentialing services have a team of skilled staff. Either they have years of experience in this industry or get trained through educational programs to upgrade themselves. There is no specific qualification required to be a specialist in credentialing. However, a two-level course offered by National Association Medical Staff Services helps the professionals to stay updated.

3.Knowledge in Specialties:

There are several specialties in the medical industry. The corresponding papers need verification from a range of authorities. The professionals should be well equipped with the latest guidelines to handle different kinds of specialties. Checking this point is very crucial if you run a multispecialty clinic. Managing different specialists and their credentialing work will get simpler through only one vendor if you have a company with the right knowledge in all fields.

4.Home Grown Provider Credentialing Solutions:

Experienced companies handling administrative work for a long period of time have gained sufficient knowledge about the pain points of the industry. Some of them are well equipped with homegrown technological solutions through customizable software plans. They can be integrated with the healthcare organization’s system to simplify workflow management. With a single team handling the entire job, the efficiency of the work will improve automatically.

5.Security Features:

Provider credentialing involves the collection and verification of sensitive documents of the healthcare providers. You must have an outsourcing partner who will keep these papers safe. Make sure that the outsourcing company has a well-defined security protocol. They must not disclose any information to an unauthorized third party without your knowledge.

On the other hand, in the case of software platforms, strict vigilance for any kind of malware or spyware should be done frequently. Make sure you discuss the security features in detail and have them written elaborately in the contract.

6.Keeping Tab on Payer Network Requirements:

One very important aspect of provider credentialing is managing the payer network requirements. Each payer has a set of specific requirements according to its own policy. Some of the basic requirements are:

  • Name
  • Demographic Details
  • MD or DO certification
  • Medical License Information (from each location)
  • Board Certificate (from the particular area of specialization)
  • Malpractice Coverage Insurance
  • DEA License
  • ECFMG certificate (for foreign medical graduates)
  • Tax ID number
  • CAQH details

Apart from these basic documents, the payer network could ask for more. The provider credentialing team must be ready to manage these different needs. In case the provider is not on the CAQH database, which is required by most of the popular payer networks, the outsourcing team should be able to assist the professional regarding the enrolment.

7.Assistance with Facility Credentialing:

The provider credentialing requirements might also change according to the kind of facility. Leading companies have professionals to deal with these issues. For example, the kinds of documents needed might change for hospital-based facilities, independent physician’s clinics, ambulatory facility or an imaging center. Based on the kind of facility, you should check if the company is well versed in handling the one specific to you.

8.Customer Reviews:

Thorough research about the details of the outsourcing company is a must before you settle down for one option. One way to be sure about the services is to check the customer reviews on their web portal. References also work well if you have one. But even if you don’t, you can read through the reviews on the various listing sites on the internet. If you find any negative comments on any portal, make sure you raise your concern when discussing the proposal.

9.Budget Plans:

The budget plan you have in mind should be in alignment with the payment plan of the company. Outsourcing proves to be cost-effective for healthcare organizations since they do not need to invest too much when trying to scale up the business. However, a range of plans proves to be helpful for a wide variety of companies.
While some have end-to-end revenue cycle management along with credentialing, some plans focus on the maintenance of provider credentialing alone. It is advisable to choose such a company with flexible options so that you can navigate between your plans according to the changing needs of the organization.

10.Help in Analyzing Finances:

Provider credentialing is very important for healthcare providers when it comes to getting paid by insurance companies. Leading outsourcing companies not only help in managing the credentialing details of the providers according to the payer networks but also provide data analysis reports with specific filters for insurance and reimbursement rates. The providers or the organizations can take decisions regarding the restatement of contracts with the particular payer networks. This will definitely help the organizations to take better financial decisions in the future.

What points do you consider when outsourcing provider credentialing to leading companies? Let us know in the comment section. For more such articles on healthcare, management, and technology, please subscribe to our blog. Send in your queries and we will definitely get back to you. For regular updates, follow us on Facebook, Instagram, Twitter, and LinkedIn.