Medical Credentialing Services
Credentialing Overview
Insurance credentialing is the process by which healthcare providers (such as doctors, therapists, clinics or hospitals) become approved by insurance companies, including Federal and State programs, to accept their insurance plans. This involves submitting an application, documentation of qualifications, licenses, and certifications, as well as undergoing a thorough review of the provider’s background, education, and professional history.
The real purpose of credentialing is to ensure that the healthcare provider meets the standards set by the insurance company, which includes verifying their education, training, licensing, and ensuring they have no history of malpractice or fraud. Once approved, the provider can then bill and receive payments from patient services who are covered by that particular insurance plan. In most cases, providers cannot treat patients, nor attain payments until the credentialing process is complete.
The process is complex and time-consuming and it varies among insurance companies, regions and states. It involves multiple steps, filling out applications and online forms, providing supporting documentation, undergoing background checks, and waiting for approval. This can take several months and the process will be greatly prolonged if not executed correctly.
In addition, providers need to recredential periodically to maintain their status and to continue accepting insurance payments. This process ensures ongoing compliance with the insurance company’s standards and requires provider’s information is up to date.
At STI, our credentialing specialists are comprised of trained and experienced professionals that understand the urgency, deadlines, logistics, provider specialties and licensing as well as the disparity between payer protocols so that we can expedite applications for the best outcomes for the provider and practice.
In our initial on-boarding process we will review your current needs, and learn about your practice, the types of services you offer (or plan to), your organizational structure, regions of operation, and your future planning. Understanding your goals will allow us to develop a more productive enrollment campaign for today and going forward.
Proven People. Proven Processes. Proven Results at STI-RCM
PEOPLE
- Experience. Our team members have been in the enrollment field for over 25 years
- Expertise. Whether your needs range from a mobile x-ray service, hospital enrollment, urgent care center, or are state agency providers, we have the knowledge to understand the requirements to complete the job.
- Access to network experts. It’s not just about what you know, but who you know. Navigating red-tape can be expedited with relationships. With the longevity of our firm, we’ve built great relationships to help advocate and expedite processing for our clients.
- Managing Deadlines. Time is money. Not getting paid for provider services is extremely costly. We’ll keep you informed of realistic completion time-frames.
- Compliance and Accuracy. Enrolling a provider isn’t about speed alone. We make certain the enrollments are correct to the provider and the business. We instruct you how you can bill claims and when you can bill for services.
PROCESS
- Efficient and Up to date. We have an established process that permits us to ensure we attain proper documentation to complete applications, reducing the likelihood of rejections or delays due to errors. Because payers will make changes to their application process, our administrative team updates our standard operating procedures in order to keep pace with these changes.
- Reduced Stress and Hassle. Receiving a returned application is stressful and aggravating. Not getting a provider representative to offer help or give a simple answer is exasperating. Our systems and management process take away the anxiety, resulting in a better outcome.
- Use of Technology. There is no substitute to a human when it comes to enrollments. The effective use of tools is crucial, however. We have sophisticated software systems that permit us to manage applications from start to finish including all documentation and correspondence.
- Knowledge of payer enrollments. The complexity of provider enrollments, including the magnitude of legacy rules by payers can cause delays. Working with the payers and our clients to mitigate waste by completing applications the first time, the right way.
- Monitoring “the monitors”. Payers don’t go out of their way to make the enrollment process easy. The complexity of the system itself causes delays. There are protocols carriers need to follow. There are time-frames applications must be completed by. By monitoring each step, we manage the payers making sure the follow the rules and hold them accountable to their responsibilities.
Selecting a vendor for your insurance credentialing involves many considerations. You want a partner that understands enrollments, the impacts to revenue and has business experience and longevity in the field. Contact us today to learn how our team can exceed the level of support you expect, permitting you to focus on what is most important and that is taking care of your patients.
ENROLLMENTS - Frequently Asked Questions
Can I treat patients and get paid while going through credentialing?
Payers have different rules and back-date provisions through the enrollment process. Our specialists will advise you what insurances you can be paid for, and regulatory matters related to seeing patients during the enrollment process.
Q: How long does it take a provider to go through the credentialing process?
Time frames from provider enrollment can range from as little as weeks to over three months. This is based upon factors which include state licensing, or delegated enrollments.
How long does it take to get started with RCM-STI?
Our on-boarding process can start within a week to begin our fact-finding initiative. We will then complete an Assessment with payers which will guide us what application requirements will be necessary. At that point, we’ll provide you time-lines for the successful completion to participation status.
What will this cost me?
Our structure is simple. We have a charge for each application that is based upon the types of applications we complete. We can review our rate structure so you have a clear understanding of your investment with no gray areas.
What if there are changes to the number of providers in my practice or the number of payers to enroll?
Our rate card for services is based on applications we process. We have flexibility in pricing models based upon the volumes of enrollments for large groups and types of practices.
What if I don’t know the number of payers I currently participate with?
In our initial on-boarding meeting, we’ll ask questions on your goals. If you are a new provider starting out, we will give you recommendations to which payers to enroll with. If you are an existing practice, we’ll conduct an Assessment that will determine which insurances you currently participate with when adding new providers or making changes to your existing panels.
How long are the terms of your agreement?
It’s easy. There is no obligation beyond the initial enrollment. We do highly recommend a maintenance program, but there is no requirement to do so.
Credentialing Maintenance Program
Payer credentialing requirements go beyond initial enrollment. The government has required continual monitoring of your status necessitating you to validate key elements. As such, insurance companies are not always effective in communications of when you need to re-credential to remain in-network. Besides the significant financial impacts if you were disenrolled from an insurance plan, you might not be allowed back in once dis-enrolled. In addition to attestations by CAQH, Medicare PECOS, State Health Departments, and legacy platforms, Federal and State administration through the No Surprise Act requires all medical providers and hospitals to maintain accurate records to within 30 days of change or steep penalties and risks of plan expulsion can result.
At STI, we have a Credentialing Payer Maintenance program that keeps you in compliance and in-network avoiding disruption of your cash-flow and costly re-enrollment. We achieve this by monthly reviewing your individual status and monitoring individual attributes unique to each payer. Sleep at night and rest assured that your insurance participation standing is being managed by a partner that understands how critical it is to you and the patients you treat.
Here are some key elements that our medical provider credentialing maintenance program manages for you:
Licensure and Certification Renewal: Healthcare providers must maintain current and valid licensure and certifications in their respective fields. This often involves renewing licenses and certifications on a regular basis according to state regulations and professional requirements.
Continuing Education: Many healthcare professions require ongoing education to maintain licensure and certifications. Providers may need to complete a certain number of continuing education credits or hours each year to stay current in their field and meet credentialing requirements
Practice Updates: Providers must keep their practice information up-to-date with insurance companies, including changes to contact information, practice locations, affiliations, and any other relevant details. Keeping this information current ensures that insurance companies can accurately inform patients of panels, and communicate with providers and process claims efficiently. The No-Surprises Act has made this a law.
Re-Credentialing and Re-Attestation: Insurance companies require providers to undergo re-credentialing and re-attestation at regular intervals. Some insurance such as Aetna Healthcare and United Healthcare require demographic verifications every three months. During this process, providers must resubmit their credentials for review to ensure they continue to meet the insurance company’s eligibility criteria.
Compliance with Regulations and Standards: Providers must adhere to all relevant regulations, standards, and contractual requirements set forth by insurance companies, government agencies, and accrediting bodies. This includes maintaining compliance with privacy and security regulations such as Health Insurance Portability and Accountability Act (HIPAA), Office of Inspector General (OIG) and the Health and Human Services (HHS).
Monitoring Changes in Insurance Plans: Providers should stay informed about any changes in the insurance plans they participate in, including updates to reimbursement rates, contract addendums and coverage policies. This awareness helps providers adapt their practices to ensure continued compliance and maximize reimbursement.
STI RCM Provider Credentialing Maintenance Program includes:
- Assessment and Verification of your participating status with insurance companies
- Tracking and maintaining participation requirements with changes to regulatory guidelines
- Retaining digital backup of all provider credentials and payer correspondence
- Re-credentialing of all participating payers
- Re-credentialing of Medicare and Medicaid Federal and State programs
- CAQH quarterly review and attestations
- PECOS and NPPES reviews and attestations
- NPI Bi-Monthly Updates
- Keeping current to Contract Amendments
- Resolution to all participation related claim issues
- Advising providers and practice prior to the credential expiration to ensure they are renewed timely
- Regular updates on all open items
- Monthly/Bi-weekly Meetings as requested by Client
By proactively managing these aspects of credentialing maintenance, healthcare providers can ensure that your credentials remain current and that you can continue to participate in insurance plans, receive reimbursement for services, and maintain strong relationships with patients.. Contact STI today and remove one more complex component of your practice to the professionals with proven results.
MAINTENANCE - Frequently Asked Questions
Why is Credentialing Maintenance important?
All providers and payers are required to maintain an accurate provider file. If you fail to meet your compliance mandates, a payer may be forced to drop you out of a plan.
I’ve been in practice for years and I’ve never had problem. Why should I want to pay for a credentialing maintenance program?
That is like saying, “I’ve never had an accident, so why should I pay for insurance?” You can’t buy car insurance after you get into an accident. The same is true with managing your provider files. Starting a maintenance program after your become excluded or fined won’t fix the problem. An ounce of prevention is worth a pound of cure.
My provider left my practice, why do I care?
If the provider re-assigned benefits to you, you have an obligation with the payers to maintain accurate files and remove them from your group NPI when they leave. Termination of a provider from your practice does not unbound the practice nor the provider from the responsibility.
How long does it take to get started?
With answering of some standard questions and gathering of key information, we can get started today.
What will this cost me?
The model is simple. Our maintenance prevention program is only $75 per provider per month. If you have a large group, clinic or hospital, we have flexible programs to meet those needs.
What if there are changes to the number of providers in my practice?
We understand the nature of healthcare. Our model is flexible to expand and contract with your practice. Because we charge a per-provider fee per month, our service rates are predictable.
How long are the terms of an agreement?
While we recommend a maintenance program of at least six months, you can enroll in a month to month agreement.