Medical credentialing involves validating the qualification and experience of a physician, nurse, or medical assistant. It is mostly performed when a new physician joins a healthcare organization. The process involves collecting the personal documents, work experience, and professional certifications of the medical provider in question.
Once the doctor is credentialed, insurance companies can reimburse the provider for their services. Physicians who are not credentialed by a health insurance company will not receive payment for their services unless it comes directly from a patient.
Improper credentialing can cause many problems, which we explain in greater detail below.
1. Lost Revenue from Non-Credentialed Doctors
If a doctor in your practice has not been credentialed by a health insurance company, the health insurance company may deny claims or reimbursements for their services.
This denial results in lost revenue to the practice. Health clinics that offer physician services prior to finalizing the credentialing process can end up with payment rejections and a convoluted billing process.
2. Using Non-Credentialed Staff to Take Clinical Notes
Credentialing ensures that only certified medical staff may see patients. If the staff of the medical clinic is certified and properly trained to perform clinical tasks, there will be fewer chances for errors. Bad clinical notes and a failure to follow standard procedures by medical assistants can cause problems in the billing process.
If there are errors in clinical documentation, they may be passed onto the billing team. Credentialing lowers the risk of billing errors and increases the rate of claim acceptance by insurance companies.
3. Reduced Quality of Care
Going through the credentialing process improves patients' trust in physicians as they know that only qualified staff is handling their treatment. Patients who see uncredentialed doctors may be concerned about the quality of their care and be less willing to undergo treatment.
They’ll likely also be concerned about the cost of their visit since it won’t be covered by insurance. On the other hand, credentialing physicians ensures that physicians are fit and qualified to handle the care process, allowing clinics to offer more services to their clients and improving the collections process.
4. Lack of Legal Protection
Credentialing protects providers from lawsuits and other legal issues. If a non-credentialed physician treats patients, then the services provided may be vulnerable to legal proceedings in the case of medical malpractice or treatments that go awry.
Proper credentialing ensures that the provider is legally protected. This coverage protects from potential penalties and other costs that may be incurred in the case of medical issues. The billing process is optimized if all processes are performed following standard operating procedures.
5. Not Engaging a Third-Party Medical Billing Company
Insurance in California can be complex. A third-party medical billing company can reduce the administrative burden on your medical practice. Since the workers in these companies are trained in medical coding and billing, they can easily prepare claims to submit to health insurance companies.
This approach reduces the expenses required for on-site billing staff and helps to ensure that claims are submitted correctly and in accordance with required policies.