The Importance of Provider Credentialing in Healthcare | TriumpHealth

Navigating the credentialing and payer enrollment process for Medicare & Medicaid, commercial, and private insurance (or payers) is a daunting task. The complexities might make you feel as if you are at odds with the payers while striving to provide excellent patient care. Facing prolonged application times, constant status follow-ups with payers, and unexplained rejections for network participation can add to the existing frustrations. This could lead to uncertainty, wondering if it was your mistake or if external variables interfered. Nevertheless, remember you hold considerable influence in this process. Let’s discuss some tactics to optimize your influence and foster better relationships with healthcare payers to get you in the network faster.

What is Provider Credentialing?

Provider credentialing is the process of verifying and assessing the qualifications and professional history of healthcare providers.
It ensures that providers meet the standards set by regulatory bodies and healthcare organizations.
Key stakeholders involved in the credentialing process include providers themselves, healthcare organizations, and payers.

Purpose of Provider Credentialing?

Provider credentialing is a crucial process in the healthcare industry that involves enrolling healthcare providers with commercial, private, and government payers, such as Medicare and Medicaid.

The purpose of provider credentialing is to ensure that healthcare providers are authorized to bill claims and receive payment for their services from payers. This process verifies that providers meet the necessary qualifications and adhere to the payer’s standards and requirements.

Additionally, provider enrollment helps healthcare organizations and providers expand their patient base by participating in various insurance networks, ensuring that patients can access care from in-network providers.

General Credentialing Process

• Initial application submission: Providers submit their credentials and information to the insurance company or payer.
• Verification of provider credentials: This involves validating education, training, licensure, and work experience by the payer.
• Background checks and primary source verification: Ensuring accuracy by directly contacting educational institutions, licensing boards, and previous employers.
• Evaluation by credentialing committee: Review the applicant’s qualifications and decide on the credentialing application.
• Final approval and notification: Successful approval results in the provider being credentialed and eligible to provide services within the network.

Common Challenges Faced by Healthcare Providers

Healthcare providers and organizations encounter many challenges today:

• Day-to-day practice management tasks resulting in lower priority for credentialing work
• Unfamiliarity with provider credentialing guidelines for private and commercial payers, as well as for Medicare and Medicaid
• The daunting task of managing extensive credentialing paperwork and applications
• Lack of credentialing staff and/or consistent attrition in trained billing staff
• Delays in insurance payments and reduced patient referrals resulted in a significant loss in revenue.

Common Challenges Faced by Payers

• Numerous challenges pervade the healthcare insurance sector, many of which are like those encountered by healthcare organizations today:
• Rising claim counts and more product offerings resulted in escalated administrative burdens.
• Staff shortages in administrative roles, particularly in customer service.
• Credentialing staff at insurance companies report insufficient training and technology tools to handle increased workloads and responsibilities.
• Obstacles in data access include a disconnect in data exchange between providers, health systems, and payers, and the sequestering of data within multiple systems in each organization.

Provider Credentialing Application Denials

• The impact of these denials is far-reaching, affecting healthcare providers, systems, and patients.
• Providers and healthcare systems face significant barriers in expanding their patient base, which can stymie growth and financial stability.
• For patients, these denials translate to reduced access to care, particularly if the denial limits the availability of specialized services in their area.
• To mitigate these challenges, healthcare providers and systems should adopt a strategy of persistence, ensuring that they consistently meet all documentation requirements and stay updated on payer-specific guidelines.

This approach improves the likelihood of successful enrollment and reinforces the provider’s commitment to delivering high-quality care.

Overcoming Provider Credentialing Denials with TriumpHealth

• Highlight Provider Value: Emphasize the benefits and cost savings a provider brings to the network, making a compelling case for inclusion.
• Advocate for Providers: Actively bat on behalf of providers to resolve enrollment issues, eliminating the burden of managing denials.
• Cost-Benefit Analysis: Present a thorough analysis of the advantages and financial benefits of allowing the provider into the network, including lives covered.

ABOUT TRIUMPHEALTH

TriumpHealth is a one-stop Revenue Cycle Management company that helps healthcare providers and organizations achieve their financial and regulatory compliance goals to maximize revenue.

We help you succeed by supporting you with Provider Credentialing, Payer Contract Negotiations, Medical Coding & Billing Audits, Practice Start-ups, Multi-Specialty Billing, and MIPS Consulting services. Being a data-driven company, we are always looking for ways to provide detailed and customized solutions to our customers. To learn how we can help you, contact us today at (888) 747-3836 x0 or sales@triumphealth.com.