Credentialing Corner, Medical Billing

# 2025 Tips for Streamlining Your Medical Billing Process with Credentialing

- January 13, 2025
- Posted by Kristen Edwards

06 Jun

Remember – there’s always a reason that takes your medical billing efforts down the drain. For a smooth reimbursement process and to manage the revenue cycle efficiently, you need a comprehensive knowledge of the medical billing process. However, efficient medical billing would only be possible when the prerequisites are met through provider credentialing. But what is provider credentialing? It plays an imperative role in streamlining medical billing operations. Today in this blog post, we’ll explore the strategies for leveraging medical credentialing services in order to restructure or reinstate your medical billing process and will see how important provider credentialing is for an optimized billing process.

## What is Provider Credentialing?

The provider credentialing process involves verifying and evaluating the evaluation of provider’s documents, including professional background checks, licensure, malpractice, and work history, aka experience. Provider credentialing is performed for a number of healthcare providers, including nurses, allied medical professionals, physicians, and medical professionals.

The provider credentialing process ensures that all healthcare providers are verified and meet the requirement and standards required to receive reimbursements from the federal and private insurance bodies for the provided services and care.

## Steps to Credentialing a healthcare provider

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Provider credentialing may require the involvement of external and internal credentialing departments. Nevertheless, the process of provider credentialing remains the same as follows;

### Gathering the data

The first step in credentialing a provider is to gather the data to verify from various organizations and sources. This data is in the form of documents, licenses, academic certification, NPI numbers, Liability coverage, a state requirement for liability, and the necessary board certification.

### Verifying the documents

This is one of the most time-consuming parts of the provider credentialing process. As secondary information sources can be inaccurate, dodgy, falsified, and biased, the main source would verify the data. The process often gets lengthy when there’s a back-and-forth movement of transferring data from the credentialing department, provider, and the primary source for verification.

Once the primary source verifies the provided documents or data, the credentialing process needs more verification; if an uncommon gap is detected in the documents, the provider may need to attach some more information or documents to satisfy the need.

### Credentialing provider

Once the information and documents are verified, the provider will be then given the privilege to perform on-site. Before they can start practicing, providers need to follow the state’s guidelines in which they want to serve and the practice field as well. State credentialing requirements can vary from state to state and field to field. Therefore, when providers opt to receive credentialing services, they should make sure to abide by the regulated regulatory requirements.

### Authorities that regulate standards of credentialing

The Joint Commission on Accreditation of Healthcare Organizations and the Federal Centers for Medicare and Medicaid Services (CMS) both have the prerequisites of meeting certain standards of care before they begin their practice.

Healthcare organizations and practitioners who do not follow the guidelines and the regulations shared by the CMS are not eligible to receive medical reimbursements from Medicaid, and the same goes for the Joint Commission on Accreditation of Healthcare Organizations. Many organizations follow the regulations shared by the Joint Commission on Accreditation of Healthcare Organizations required for Medicaid reimbursement.

However, states and jurisdictions, on the other hand, regulate their own instructions, which is an additional criterion to meet to serve the state.

Federal regulations are standardized by the group of accreditation authorities, which include;

– Utilization Review Accreditation Commission (URAC)

– The National Committee for Quality Assurance (NCQA)

– Det Norske Veritas (DNV)

– The Accreditation Association for Ambulatory Healthcare (AAAHC)

## Common Documents and Information required for Provider Credentialing

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– Name

– Gender

– Previous/other names

– Ethnicity

– Email address

– Mailing address

– Daytime phone number

– Recent photograph

– Citizenship information

– Date of birth

– Current CV

– Social Security number

– Residency

– Education and training

– Licensing

– Specialty certificates

– Specialties

– Qualifications

– Patient age focus

– Career history

– Languages spoken

– Medical group affiliation

– Hospital affiliations

– Practice address

– Practice phone number

– Practice Tax ID Number

– National Provider Identifier (NPI) number

– Primary practice contact

– Board certification

– Sanctions or disciplinary actions

– Acceptance of new patients

– Proof of professional liability insurance

– Peer references

– Continuing medical education documents

– Malpractice claims history

## How long does the Provider Credentialing take to complete?

Even if you have provided all the documents and information mentioned above, the verification process takes an exceedingly long time. Under the most favorable circumstances, a provider would be credentialed expectedly in thirty days and can start working in an organization in his field of practice. On the other hand, the process can take up to 60-90 days which is too often. And for insurance companies, due to the excessive day-to-day workload, the credentialing process can take longer than six months even.

According to credentialing experts, the process takes longer than usual because of the specific state requirement of certain fields of practice. In addition, the process takes time for the fresh graduates as they are seeking medical graduation certificates from the schools and the practitioner involved in the illegal practices or malpractice as seeking important information for the case, studying the cause, and verifying the conclusions can take longer than usual.

Plus, many times, organizations are reluctant to change their methods of working. Several medical credentialing and healthcare organizations still use manual data handling and paperwork to reserve data. This takes even longer to complete the credentialing process.

Healthcare organizations cannot complete the medical billing process for providers or even for the practices without being credentialed by the authorities.

Now that you know the importance and the process of credentialing let us explain the medical billing process and optimize it by applying the following techniques.

## Top Tips for Streamlining Your Medical Billing Process with Credentialing Services:

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Medical billing is an essential and time-consuming process, but it can be streamlined with effective and optimized strategies to prevent claims denials and delays in payments. Here are some of the core steps in medical billing that every medical organization follows, which need to be understood further;

### 1. Understanding the Importance of Credentialing:

To streamline the process of medical billing, first, the organizations and associated authorities need to identify the significance of provider credentialing.

With provider credentialing, a practice or healthcare facility can gain countless advantages, and they are more likely beneficial in the reimbursement process.

With credentialing, it gets verified that all healthcare professionals in the healthcare organization are appropriately credentialed. This ultimately minimizes billing errors, reduces claim denials, and optimizes reimbursement rates. This leads to improved cash flow and overall operational efficiency.

### 2. Utilize Credentialing Services:

There’s no doubt that healthcare professionals serve a most demanding responsibility that engages them to provide care to the best of their abilities. This is why, oftentimes, credentialing gets delayed and, thus, the reimbursements from insurance providers.

The task of credentialing can be enhanced and expedited by engaging professional credentialing services that can help greatly in simplifying the process and save time and resources.

These services specialize in verifying and maintaining the credentials of your healthcare providers, ensuring compliance with all regulatory requirements as they are more updated with the current trends of credentialing and the technological improvements that have been made lately to the process. They handle tasks such as collecting and verifying provider information, conducting background checks, managing re-credentialing processes, and initiating any necessary documentation required at the time of credentialing or claim submission.

### 3. Stay Up-to-Date with Regulatory Changes:

As said, medical billing is subjected to make regular regulatory changes to the process. In order to streamline the processes of medical billing effectively, it is crucial to stay updated with the latest regulations and requirements.

One of the important things that need to be kept in mind is that the claims can be dismissed because of any minor reason. Wither it would be missing or outdated information. By teaming up with a credentialing service provider that actively monitors and adapts to these changes, you can ensure compliance and avoid potential penalties or claim denials.

### 4. Centralize and Digitize Credentialing Data:

Many times in-house credentialing and biller teams are reluctant to use the technology and keep minimal interaction with the upgraded software and gadgets.

Maintaining a centralized and digitized system for storing and managing credentialing data can significantly streamline your medical billing process. By eliminating paper-based processes and implementing a secure electronic system for billing and coding like EHR, you can easily access and update provider information, track credentialing statuses, and share necessary documentation with insurance companies when needed.

### 5. Automate Credentialing Processes:

Once the tasks are assigned to software, it can save you time and energy, and you can automate the credentialing and even medical billing process easily. Automation can help eliminate manual errors and reduce administrative burdens associated with provider credentialing. Utilize credentialing software or tools that automate the verification process, track expiring credentials, and send timely reminders for re-credentialing. Automation not only saves time but also ensures accuracy and consistency in managing provider credentials. When the medical billing process is outsourced, the third-party medical credentialing and billing service providers having the skills and data, perform the process more quickly. Otherwise, when you want to have the process in-house to automate the task, you may need to train your staff about the software and its use.

### 6. Establish Effective Communication Channels:

Medical billing claims can easily be denied when there’s a human error, or any coding requirement is not met. When the patient is released after receiving the treatment, claims should take immediately start; communication is required across channels.

For this, efficient communication is vital when streamlining the medical billing process with credentialing services. Establish clear channels of communication with both internal staff and external credentialing partners. Regularly communicate updates, share necessary information, and maintain open lines of communication to address any potential issues promptly.

### 7. Monitor Performance Metrics:

A practice can only prosper when its medical claims get approved on time, and the revenue management cycle is running smoothly. This ideal situation can be achieved by streamlining the medical billing process, which ultimately needs proactive measures.

To assess the effectiveness of your streamlined medical billing process, establish key performance indicators (KPIs) and regularly monitor them. Track metrics such as claim denial rates, reimbursement turnaround time, and provider enrollment timeframes. Analyzing these metrics will help you identify areas for improvement and make necessary adjustments to further streamline your processes.

## Conclusion:

In the ever-evolving healthcare landscape, provider credentialing plays a vital role in streamlining your medical billing process. You can optimize your medical billing operations by understanding the importance of credentialing, utilizing credentialing services, staying up-to-date with regulations, centralizing and digitizing credentialing data, automating processes, establishing effective communication channels, and monitoring performance metrics. Streamlining your medical billing process with credentialing services improves operational efficiency, ensures compliance, reduces claim denials, and ultimately increases efficiency.

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