Coding and Credentialing - Are You Doing It Right?
Are You Growing? As your business grows, so does the importance of contracting and credentialing. Imagine you are ready to expand to a second location or add a new line of business. You have devoted hours to developing the best business plan, secured the location, recruited providers, ordered equipment, and are ready to launch! But, are you ready to get paid for your services? Will You Be Paid? Are your providers credentialed in the appropriate plans for the new location? Are your contracts with payors reflecting the new location or line of business? Are you compliant with local, state and federal regulations? Without proper credentialing and contracting, you will not be eligible for reimbursement available as an in-network provider. Depending on the health plan design, some plans provide benefits for out-of-network providers (PPO plans). These plans are subject to higher deductibles, higher co-payments and lower co-insurance payments. If the plan only pays in-network benefits (HMO plans), the provider will not receive any reimbursement from the payor. Do You Understand Credentialing? The definition of credentialing is the process of formal review of the qualifications of a health care provider who has applied to participate in a network, system, or health plan. While the definition is simple, the process to get a provider credentialed is not simple. The collection of documents, primary source verification, creating/updating the provider’s core file, tracking application status, and linking the provider to the appropriate contract is complex. Mark Hobgood Chief Credentialing and Contracting Officer WOWZA Management Services