The Role of Credentialing in Ensuring Smooth Revenue Cycle Operations

What is credentialing?

According to 54% of medical practices in MGMA’s survey, denials due to provider credentialing issues have increased since 2021. Yet, 85% of provider credentialing applications lack critical information. To address the information gap, let’s clearly define what credentialing means and its crucial process.

Credentialing is assessing a healthcare provider’s academic qualifications and clinical practice history. It has been practiced for 1000 years to assure patients that they receive the highest level of care from qualified, trained, and licensed healthcare professionals. The credentialing process has two main goals: upholding healthcare standards and maintaining medical proficiency.

Credentialing protects the integrity of practicing the art of providing care through rigorous standards set by accrediting bodies and institutions. In other words, the most stringent scrutiny applies to those who will be handling people’s lives.

Understanding the crucial credentialing process

To be fully credentialed, medical professionals undergo this 2-step application process.

• Pre-application: A screening process to check unrestricted licenses, disciplinary actions or sanctions by insurers, hospitals, etc., criminal history, board certifications, and general health status. Questionable credentials at this point will require applicants to submit more materials and contact appropriate boards, agencies, or organizations for further assessments.
• Formal application: After meeting the minimum requirements for credentialing, they can proceed with the final application, which includes detailed information on their education, training, work history, licenses, certifications, and references. The applicant should acknowledge receipt of the hospital bylaws, regulations, rules, and the Code of Conduct. Remember, a copy of the bylaws should be signed, dated, and returned to the credentialing committee.

Based on the review of the credentialing committee or body, a decision is made to either grant, deny, or defer the credentials. In some cases, additional information or clarification may be requested.

Note: Once credentialed, a practitioner may apply for specific clinical privileges. This involves detailing which medical procedures or services they are authorized to perform within a facility.

Credentialing doesn’t stop at the final decision—we must continuously monitor the professional’s performance. Recredentialing typically occurs every two to three years. At Synapse RCM, we can guarantee that recredentialing won’t fall into the background as you manage your practice. Our expert credentialing professionals will arrange everything you need and contact anyone needed.

The fundamental role of credentialing in RCM

The importance of credentialing in healthcare can’t be emphasized enough. For each healthcare organization, credentialing proves they care about their patients. It also underscores the medical community’s commitment to preserving the highest competence and ethics.

However, more than that, credentialing can make or break your revenue stream. Without proper provider credentialing, the following issues can happen:

• Inability to bill for services: Providers can only bill services they can perform. Credentialing can help verify their competency and ability to bill for services provided, reducing the chances of a cardiologist performing neurosurgery.
• No reimbursements: Insurance companies and government payers won’t reimburse unqualified providers.
• Potential lawsuits: Failure to check a provider’s legitimacy can result in malpractice, negligence, and other issues, which can cost your patient’s trust, your company’s reputation, and revenue.

If your practice’s goal is financial health, credentialing can ensure a smooth RCM that can positively impact revenue capture and overall organizational performance.

Make the strategic move with Synapse RCM as your trusted credentialing partner

Don’t let the myriad regulations and requirements of credentialing make you lose sight of what’s important—your practice’s success and focus on patient care. Our Synapse experts specialize in credentialing, ensuring compliance with the latest standards and reducing the risk of denials. We see the highly complex and time-consuming process as an opportunity to innovate, connecting you with teams that simplify credentialing and maximize RCM.

Embrace outsourcing for credentialing today and make the strategic move to smoothen your revenue cycle operations now. Contact us for a FREE consultation!

Source:

Facmpe, L. W. R. I. M. (2021, April 21). Five steps to easy physician credentialing. Physicians Practice. https://www.physicianspractice.com/view/five-steps-easy-physician-credentialing

More than half of practices report credentialing-related denials on the rise in 2021. (2021, August 26). https://www.mgma.com/mgma-stats/more-than-half-of-practices-report-credentialing-related-denials-on-the-rise-in-2021

Patel, R., & Sharma, S. (2022, October 24). Credentialing. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK519504/#:~:text=Credentialing%20is%20a%20formal%20process,their%20ability%20to%20practice%20medicine

Schmidt, T. (2021, May 14). How much revenue is your healthcare practice losing due to inefficient revenue cycle processes? https://www.mgma.com/articles/how-much-revenue-is-your-healthcare-practice-losing-due-to-inefficient-revenue-cycle-processes-