Medical or Insurance Credentialing is the process of assessing the qualifications of medical professionals who wish to bill insurance companies for the healthcare services they provide. Medical professionals that want to be reimbursed for their services as an in-network provider must complete this credentialing process with major insurance companies that work with their field of healthcare.
As part of the credentialing process, medical insurances will assess the medical professional’s training, expertise, experience, and education in the services they wish to provide and be reimbursed for. The process usually begins with the provider (or provider representative) submitting a credentialing application that lists their qualifications, training, and expertise. Different medical insurances have their specific applications and each application must be filled out so it meets their unique requirements.
After the insurance companies verify the provider’s expertise and experience, they must assess whether that provider meets the internal requirements that are needed to serve as a provider of services for their insurance company. If the provider meets these internal requirements, the insurance company will approve the credentialing application. After that, the insurance company will issue a participating provider contract that authorizes the provider to bill the insurance company for their services and be reimbursed for these services.
If the provider does not credential properly with the medical insurance company, they can still bill them, but they will only be reimbursed at the out of network provider rate.
Medicare and Medicaid require most providers to be credentialed with them if the provider wants to be paid for their services. In some states, there are managed care organizations (MCOs). An MCO is a type of health insurance that has a contract with a healthcare provider or medical facility to manage care for a patient at a reduced cost. Some states require the providers to be credentialed with Medicaid before they can apply for credentialing with MCOs.
The whole credentialing process can take months to complete and usually requires multiple follow up calls with the different insurance companies. For best results, many providers usually leave their credentialing to the hands of the professionals. KLN Billing Professionals has extensive experience with credentialing healthcare providers in Physical and Occupational Therapy. We can credential providers with all insurance companies – in or out of the network. We also make sure to regularly follow up with the insurance companies because of the long waiting period that sometimes comes with credentialing providers to the network. KLN Professionals can also set providers up to receive Electronic Funds Transfer (EFT) payments. EFT payments have several advantages over receiving paper checks.
Electronic Funds Transfer is the method of electronically moving payments from one bank to another. It usually does not require the need for any bank employees and also eliminates the need for paper checks. The transfer can happen between different accounts in different banks or different accounts within the same bank. The terms EFT and ePayments are used interchangeably. Direct deposits, automated teller machines (ATM), eChecks, virtual cards, and personal computer banking are all different forms of electronic funds transfers.
More and more businesses are now using EFT as their preferred method of being reimbursed. Electronic funds transfers have several advantages over being paid via paper checks.
Many providers also enroll in Automated Clearing House Payments (ACH) which is a type of EFT. An ACH payment involves moving payments from one bank to another bank with the involvement of an Automated Clearing House Network. The ACH system is managed by the National Automated Clearing House Association (NACHA). There are three key players involved in the ACH payment process.
We provide excellent care for our providers by credentialing them with all of the major insurance companies, following up with the insurance companies, and setting them up with electronic funds transfer.
Leave your credentialing to the hands of the professionals by calling 678-549-1794 today!