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What Is The Time Taken For Credentialing?

 Medical Billing Services

When building a medical practice, EHR & credentialing is an important step to be taken in the right direction. It refers to the process to get enrolled in the list of preferred service providers of an insurance company. With a growing number of people opting for a health insurance, it is absolutely necessary for every healthcare professional to get credentialed. This can be a lengthy process that may take 3-4 months of paperwork, documentation, and correspondences. Apparently, there is no definite method to know this time. Some payers can complete it quickly while others may take a long time. Here, it is important to understand the process of credentialing to know what it truly entails. With complete information, it becomes easier to understand why this process should be preferably handled by the professionals.

Application for Enrollment

It can be daunting to submit an application for enrollment to the payer. The process is challenging and you need to choose the right application format depending on your specialty. The number of pages in an application may vary from 3-300. It is, indeed, overwhelming. Firstly, you must submit a Letter of Interest to the company. Upon receiving this letter and checking your NPI and Tax ID against their existing database, the payer will decide if they can allow you into their network. Here, they consider the facts like the number of providers from your locality registered with them and their field of specialization.

Completion of the Application

You must consider yourself blessed enough if you receive this application from Payer. Now, you need to organize a lot of things including your educational degrees, medical certificates, policies, practice portfolio, and CMEs. Keep them handy to answer the questions being asked in applications form. They may ask a lot of questions about your past jobs, medical licenses, and other explanations. Here, they can also put up queries related malpractice history, criminal history, and civil suits if any. Then, there are questions related to the ownership of your practice. You need to answer all these questions correctly to avoid facing the Medical Board.

Submitting the Application

After completing the application, you must duly submit it with all the required documents. Post submission, stay alert to follow up, preferably per week. This way, it becomes easier to provide the clarifications required by the payer and information omitted in the application.

Comparison with CAQH Profile

When you submit your application, the payer will compare the information provided in this document with your details registered on CAQH profile. If they find any discrepancy in this application, this process may take longer than you anticipated.

Checking of Licenses

Every license held by the practice will be closely scrutinized by the payer. They will check their database for discrepancies in information. It can also help in showing the malpractice claims history. They can also check with the Medical Board to know about the current status of your license.

Contract Signing

After all these steps, you will get the notification stating that your credentialing is finalized. It’s great but, not the end. Now, you need to sign a contract. The payer will prepare this contract and they will assign you a schedule of fee as well. Once you’ve signed the contract, upload it on their sophisticated Claims Adjudication Software. This process may further take the time of some weeks. Unless this procedure is completed and you receive a notice stating the effective date along with a confirmation of the contract and its uploading, you shouldn’t begin the claim settlement at your practice.

In a nutshell, the process of credentialing and contracting is cumbersome and time-consuming. Any error may delay the process or contradict your chances of completion. Here, you must know that the quality of this process influences your revenues. It is a sensitive subject matter that must be handled by the skilled professionals.

Initial Setup Fee

This is a one-time fee that includes the following:
Credentialing Database Setup: Costing around $250.00- $500.00
It is an important step of the initial setup process. Here, the pricing depends on your existing file layout and its compatibility with a credentialing file. If these two are closely related, the costs will be on a lower side. However, if your system needs a unique file layout, this may increase the time and resources required for setup.

Mapping of Information to State/Facility/Payer Specific Panel: Costing the Actual charges of programming
The information of this process must be mapped to the paneling file used by payer or any other entity from your unique HBN credentialing file. The charges for this process are generally less than $100/ mapped application.
For instance, if the payers in your state have a uniform application layout for this paneling process, you will be charged this fee only once. However, if every payer uses a unique paneling application process, you will incur this fee for each application mapped. Same will be the charging process if there are unique applications for allied health practitioners.

Fees Charged on a Per File Basis
  • The Charges for Initial Physician Credentialing are approximately $155.00 per physician
  • The Charges for Physician Re-Credentialing are approximately $145.00 per physician
  • In this regard, Physicians include DMD, DDS, DPM, MD, DO, DC, and OD.
  • The Initial Physician Credentialing price per file includes AMA/AOA and NPDB charges.
Apart from these, there may be some fees charged by the sources. These fees are additional to those listed above. However, they are usually nominal. They may include
  • Initial Allied Health Credentialing: $150.00/practitioner approximately.
  • Allied Health Re-Credentialing: $140.00/practitioner approximately
  • Here, the allied health providers include, FNP, MFT, NP, LA.C, OT, CRNA, LCSW, PA, PT, RN, SLP, PhD, and all those practitioners who were not included in the Physician category above.

Charges for Dynamic Credentialing: Approx. $16.00

These charges are based on the number of documents. If a client chooses to receive the files through an email, the number of documents includes this PDF as well. For a license nearing its expiry, this fee is charged nominally at $16.00. However, when both your license and DEA have their expiry due shortly, you may be needed to pay $16- $32 for verification and updating of the existing PDF file.

The Cost of Paneling Packaged with Credentialing: $75 per provider/ app

When you opt for a standalone paneling, the consumption of HBN’s resources will match the credentialing procedure. Hence, their pricing will also be similar. Here, you should also check if the mapping process from a credentialing system can be done easily. In such cases, the pricing model will match the amounts stated above for per panel app and initial mapping.

What it may look like?

Let us assess a likely scenario with a group of 10 physicians including 2-nurse practitioners. Assume the creation of a project and pricing model for their credentialing and contracting. Supposedly, you can assume that this state has a uniform application for all the payers. This group may approach the professionals for setting up an initial credentialing file for their quality assurance program, submission of credentialing information to the hospital where they practice, or any other reason. They ask to map the credentialing file to the uniform payer application format of the state. It is a part of this process for becoming in-network providers for the insurance companies.

Here the prices are charged as follows
  • Initial setup of Physician Credentialing File for the group - $300
  • Initial Setup of Allied Health Credentialing file - $250
  • Mapping Charges for Physician State Uniform App - $100
  • Mapping Charges for NP State Uniform App - $100
  • Initial Credentialing for 10 Physicians charged @ $155 each - $1550
  • Initial Credentialing for 2 NPs charged @ $145 each - $290
  • Dynamic Credentialing Updated per provider - $192
  • The Total Cost of this project over the year will be $2782

Benefits for Your Practice

  • After completion of this scenario, you will receive populated credentialing files for both physicians and NPs. They are unique to your group and ready to be used. You can also submit them to the hospital or any other entity.
  • Automated electronic mapping helps in populating the state uniform application format of payers for physicians as well as NPs. It can be submitted easily to any payer.
  • The initial copies of documents like licenses will be available in PDF format in the file.
  • It will raise flags related to permanent documents and their required updates. It helps in keeping the files updated.
  • There is a confidential electronic file format with data retrieval and consistent formatting features for short biographies, CVs, provider lists, and other promotional materials depending on your preferences.
This abovementioned scenario is intended to display the estimated costs of this entire process including creation and maintenance of credentialing and paneling information related to a healthcare practice. These costs may vary according to the varied demands of practitioners. Contact Nationwide Healthcare Billing Services for further queries (call us: (866) 880-4252, Email: gary@nwhcbs.com).