Credentialing Corner

# How Medical Credentialing Impacts Reimbursement

- April 26, 2023
- Posted by Kristen Edwards

26 Apr

The process of checking the credentials, education, experience, and competence of a healthcare practitioner in order to determine whether or not they satisfy the requirements for their particular specialty is known as medical credentialing. The procedure is critical in the field of healthcare since it guarantees that patients will get treatment from specialists who are certified and experienced. However, medical credentialing also has an effect on how much patients get reimbursed for their treatment.

In this blog, we will cover the ways in which medical credentialing impacts healthcare reimbursement, specifically how it can assist healthcare professionals in increasing reimbursement rates, reducing claims denials, and improving revenue cycle management.

## Why Is the Process of Reimbursement Troublesome in Medical Credentialing?

When it comes to medical credentialing, reimbursement may be a source of frustration for a few different reasons:

Complexity: The process of reimbursement may be exceedingly difficult due to the fact that various payers have varying standards and restrictions. Because of this, it may be challenging for healthcare professionals to understand the procedure and verify that they are submitting claims in the right format.

Time-Consuming: It is possible that the process of filing claims and following up with payers will take a significant amount of time. This may provide a particularly difficult challenge for healthcare practitioners who are already swamped with the treatment of patients as well as other administrative responsibilities.

Denials: Even when claims are appropriately filed, they may still be rejected for a number of reasons, including mistakes in the paperwork or code. Among these reasons include the possibility of human error. The providers of healthcare must therefore devote additional time and money to the process of appealing these rejections.

Impact on revenue: Because reimbursement is such an essential component of healthcare income, any delays in receiving it or being denied it may have a major and negative effect on the bottom line of a healthcare provider’s business. This might put a strain on the financial resources of healthcare practitioners and the practices in which they work.

## 3 Ways Medical Credentialing Impacts Reimbursement

Medical credentialing impacts reimbursement in the following key areas:

- Increasing Reimbursement Rates

The credentialing of medical professionals is a critical component in the calculation of the rates of reimbursement for healthcare professionals. The qualifications, level of education, and level of experience of a healthcare professional all have a role in how much an insurance company or government payer is willing to pay for their services. Credentialing in the medical field assures that those working in the healthcare industry have the education, training, and experience required to be eligible for higher reimbursement rates.

For the sake of illustration, a general practitioner who does not possess a specialty certification in cardiology may be eligible for lower payment rates for cardiac services than a healthcare professional who does possess such a certification. In a similar vein, medical practitioners who have board certifications in their respective specialties have the ability to negotiate higher rates of compensation with insurers.

- Eliminating or Minimizing Claim Denials

Credentialing medical practitioners may assist in cutting down on the number of times their claims are rejected. Claim rejections occur when insurance companies reject reimbursement claims owing to mistakes or omissions in the process of submitting a claim. These errors or omissions may be caused by human or computer error. Credentialing in medicine assists medical practitioners in ensuring that their claims are accurate and comprehensive, hence lowering the likelihood that their claims would be rejected.

For instance, the National Provider Identifier (NPI) of a healthcare practitioner may be validated via the credentialing process, which is a vital step in the process of filing claims for payment. Claim rejections are possible outcomes that might result from inaccuracies or omissions in the NPI. Credentials and licenses held by healthcare professionals are checked throughout the medical credentialing process to ensure that they are up-to-date and legitimate. This helps to lower the risk of claims being denied owing to credentialing problems.

- Improving Revenue Cycle Management

The improvement in revenue cycle management is another potential benefit of medical credentialing. The term “revenue cycle management” refers to the process of managing the financial operations of a healthcare institution, beginning with the registration and billing of patients and continuing through the filing of claims and the subsequent payment of those claims.

Credentialing in medicine assists medical practitioners in streamlining the process of revenue cycle management. This is accomplished by ensuring that their claims are correct and comprehensive, which in turn reduces the likelihood of claim rejections and delays. Additionally, it assists medical practitioners in negotiating better reimbursement rates, which ultimately results in an increase in income.

For example, medical credentialing may assist healthcare personnel in recognizing and addressing difficulties related to revenue cycle management, such as improper coding or incomplete claims, therefore cutting down on the amount of time and resources required to handle such problems.

## Real-World Examples

The process of medical credentialing has had a considerable effect on healthcare reimbursement. For example, research conducted by the American Medical Association discovered that medical practitioners who had board certificates were eligible for greater payment rates than their counterparts who did not have board certifications. The survey also discovered that the percentages of claims being denied for healthcare providers who have board certification were much lower.

One other example of this would be the Magnet Recognition Program run by the American Nurses Credentialing Center. The program honors medical facilities that are able to offer patients treatment of the highest possible quality while also adhering to severe credentialing requirements. Companies in the healthcare industry that have been awarded the Magnet certification have reported higher levels of patient satisfaction, lower rates of nurse turnover, and greater financial performance.

### The Bottom Line

Medical Credentialing is an essential component of the healthcare reimbursement process, as it influences payment rates, the number of denied claims, and revenue cycle management.

Credentialing medical professionals may also assist in streamlining revenue cycle management, which in turn can improve financial performance. Medical credentialing needs to be given top priority by healthcare professionals and organizations in order to guarantee that practitioners will live up to the expectations of their field and will be compensated fairly for their services.

Sybrid MD is a leading provider of Credentialing in medical billing and coding services, offering a wide range of solutions to healthcare providers across the United States. With a team of highly trained and experienced professionals, Sybrid MD helps healthcare providers navigate the complex world of reimbursement and coding, ensuring that claims are submitted accurately and efficiently. Whether you’re a small practice or a large healthcare organization, Sybrid MD has the expertise and resources to help you streamline your billing processes and maximize your revenue. So if you’re looking for a reliable and trusted partner for medical billing and coding, look no further than Sybrid MD.

### Frequently Asked Questions (FAQs)

What types of healthcare providers are eligible for reimbursement in medical credentialing?

All healthcare providers who are credentialed and contracted with insurance companies, Medicare, or Medicaid are eligible for reimbursement.

Why is credentialing important in medical reimbursement?

Credentialing is important in medical reimbursement because insurance companies, Medicare, and Medicaid require providers to be credentialed and contracted with them in order to receive reimbursement.

What is a claims submission process?

A claims submission process is the process of submitting claims to the insurance company, Medicare, or Medicaid for services rendered, including all necessary documentation and coding.

What is a claim’s denial?

A claims denial is when an insurance company, Medicare, or Medicaid rejects a claim submitted by a healthcare provider for reimbursement.

What are the common reasons for claims denial?

Common reasons for claims denial include incorrect coding, lack of medical necessity, incomplete documentation, and services provided that are not covered by the insurance plan.

How can healthcare providers appeal a claim’s denial? Healthcare providers can appeal a claim’s denial by submitting additional documentation or coding, or by appealing the decision through the insurance company’s, Medicare’s, or Medicaid’s appeal process.

### Related Links

> What Is CAQH Credentialing? Why Is It Required by The Provider in Credentialing?

> Can Doctors Collect Deductibles Upfront? – Point-Of-Service Collections

> How Long Does Credentialing Process Take?

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