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What Does It Mean To Be Contracted or Credentialed With an Insurer?

Healthcare insurance is among the most popular ways patients seeking treatment pay their respective experts. Insurers can often require active contracts with healthcare personnel to reimburse for services rendered. Insurance credentialing can help avoid claim denials, improving your practice’s profitability. Here’s what it means to be contracted or credentialed with an insurer:

What Is Credentialing?

Credentialing involves verifying a medical provider’s professional details, qualifications, and history to confirm professionalism. Healthcare providers often have to submit documents like certifications, licenses, practice history reports, and references to the insurer. The insurer can then validate the documents and credentials through primary source verification.

Credentialing can help insurance companies make sure the healthcare expert is qualified to provide their members with quality care. Insurers can also investigate any malpractice claims the medical provider might have been implicated in, offering them liability protection. Credentialing can also help insurers verify a provider’s legitimacy and ability to meet their standards and requirements.

What Is Contracting?

Contracting involves negotiations and signing terms and conditions dictating a healthcare provider’s relationship with the insurer. Such contracts can specify the rights and obligations of the provider, like services, billing and payment procedures, quality standards, and dispute resolution mechanisms. Some contracts can also specify claims processing timelines and performance expectations for each partner.

Contracting can help establish a mutually beneficial partnership between insurers and medical providers, allowing your practice access to the payer’s members. The contract can also help define the scope of your practice and participation level, like whether you are preferred or non-preferred, or exclusive or non-exclusive.

Importance of Insurance Contracting and Credentialing

Insurance credentialing and contracting can help medical practitioners partner and work with health insurers. Here’s how they influence their eligibility, reimbursement, and liability:

  • Eligibility: Insurers use the credentialing and contracting process to find providers that match their quality standards. Credentialing and contracting can allow you to see the insurance company’s members and get paid for services you render to any of them. Access to the insurer’s members can help grow your practice and make it more profitable.
  • Reimbursement: Contracting and credentialing can determine the frequency and number of payments for your services by the insurer. Insurance companies can often offer credentialed and contracted providers a higher rate for services rendered and shorter payment cycles. This can help improve the practice’s revenue cycle and promote profitability.
  • Liability: Contracting and credentialing can help determine a provider’s legal protections. Credentialed and contracted healthcare professionals may often have less exposure in malpractice lawsuits and more liability coverage. This can help prevent financial loss and protect your reputation as a healthcare provider.

How to Get Contracted and Credentialed

Credentialing often precedes contracting since the insurer has to verify documents and ascertain the medical provider can meet their member’s needs. Both processes can be lengthy since they may involve document presentation, communication with third parties, and follow-ups. While many credentialing and contracting processes can be standard, some insurers may need more information, so research their procedures.

Common documents insurers may require for the credentialing process may include:

  1. An application form
  2. Copies of your resume
  3. Transcripts and diploma copies
  4. Malpractice insurance copy
  5. Copies of your operating licenses
  6. Board certification copy
  7. DEA registration copy
  8. A list of hospital affiliations
  9. A list of references

Registering with the CAQH (Council for Affordable Quality Healthcare) can help medical personnel centralize credentialing information. When applying for credentialing with multiple insurers, this can help you update information once. Insurance companies will handle approval and then confirm your status, after which you can sign a contract for your partnership. After the contract signing, insurance companies will finalize and activate it, allowing you to start serving their members and billing them for services rendered.

Hire Insurance Credentialing Experts

Credentialing and contracting can affect your practices’ reimbursement, eligibility, and liability. The process may involve verifying credentials and qualifications, which can be lengthy. Working with insurance credentialing experts can help make the process seamless and efficient. Their attention to detail can help avoid errors that can result in delayed payments.

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