Wiki Communicating Credentialing Par and Non par providers

[mra1110]

Out of curiosity, how do other offices communicate from their credentialing department to billing department when providers become par with an insurance company? I'm looking for ways to improve our communication and a more streamlined process.



Our facility is under one umbrella for all of doctors offices. So we have one credentialing department and a billing department. Our current process, is providers have a claim hold built and our billers use an excel spreadsheet that list the providers name, NPI, Taxonomy, Office name, the insurances as they become par with the par dates. We have designated staff in our department that communicates with credentialing to update this as par dates are requested. Below is an example.




SMITH, DOCTOR MD Full Cred PMS Pain Management Aetna 10/23/18,Aetna Better Health 10/23/18,Buckeye 5/1/16,Caresouce 3/1/16,Cigna 1/1/16,Frontpath 1/1/16,Molina 11/13/18,Multiplan 10/23/18,NWOHP/OHC 01/01/16,Paramount 10/23/18,Paramount Elite 7/1/2018,SummaCare 1/1/16,Tricare 10/23/18,UHC Commerical and Medicare 08/31/16




I'm curious, what other processes are within other organizations?

 

[TThivierge]

H
I use to do credentialing and billing in clinic office with 10 docs on staff. When hired new docs or clinical staff, must do questionnaire listing demographic info, college internship, license number and vitae data. Or they can print it out from CAQH website give to you. Then use this as guide to complete the CAQH online or hard copy insurance credentialing or if online apps. Or have human resource give it to you ASAP to add the data to CAQH for new clinical person. This is vital with your facility so when get working come in can bill and get paid for their treatments provide. I also kept all this on Excel document. You might set up ticker fil or send group email to all involved to check every month when provider can now bill get covered and when their license needs to be renewed. Some payers may back track and pick up payment since it takes about 90 days to get a provider credentialed. Send malpractice insurance too which is required.

If possible create a list of your insurance payers credentialing address, each Rep's name, fax and email address, direct phone number, contract details and list of data they need. And send a Christmas card each year to the credentialing person make them feel special or pack of gum or something keep you in mind to please. Umm a little nice gesture can go a long way. Well just a suggestion

Also add provider to your state work comp agency since each doc/provider get own ID # for being WC provider at your facility. This helps incase work comp (hurt on the job) patient's case pops in the office

You might want to keep a running list of pts. seen by uncredentialed providers and when get approved to rebill. Or track insurance denials from the provider not approved yet. You could use Excel list or MS outlook email task system as reminder.

I hope this data helps you!
Lady T

 

[csperoni]

I think a shared excel document that your credentialing people update and your billing staff can view seems about right. Depending on the size of your organization and number of providers, either set a specific timeframe (once a week, once every 2 weeks, once a month) that your billing staff should check for updates or require credentialing to immediately notify billing upon participation. Maybe highlight or mark in another color recent updates to make it easier to check.

Regarding a running list of patients - if you have an integrated billing/EHR system, you may not need to do this manually. When we were private practice, and I was both the credentialing department and billing department, the system allowed me to hold claims for any specific provider for any specific plan. Once credentialing approved, I would release all the claims for that carrier (never letting it go past timely filing). At any given point in time, I could simply see what claims (number and dollar amounts) were being held for each insurance for each provider, so no need for a manual spreadsheet of any kind.

As a side/related note - not all insurances will backdate. We do everything possible to keep a new provider busy without providing services we are not going to be paid for by careful, proper scheduling and adjusting the workflow of new providers. Depending on your type of office, this may or may not be an easy task. Also, start credentialing as soon as a contract is signed, well in advance of provider's actual start date.