What is Credentialing? and the Importance of Credentialing in Healthcare

Provider credentialing is a verification process of Healthcare provider information and approve them as a participating or in-network provider. Provider experience, degree or education, work history, licenses, and medical broad certification, liability, Malpractice practice, etc information would be verified.

After successful verification. Credentialing team from payer end will approve or may deny the credentialing form.

Process of Credentialing Insurance

Provider Contracting:

Network operations / Contracting team will identify out of network providers by current claims data analysis. The contract will establish the contract with Healthcare provider, post positive response, contracting process would be initiated. Fee schedule discussions would be performed by both insurance and provider agree to one fee schedule. Contract sign off would be completed, a healthcare provider would be processed as an in-network provider. All the remaining contract sign-off and all other credentialing activities will be processed.

Credentialing and contract approval, Fee-schedule would be updated in claims management system as well as all-payer end systems. All claims submitted by the provider will be processed as in-network claims and provider will get full reimbursement as per the contract and Fee-schedule.

Provider credentialing
Difference Between In-network and Out of Network Providers:

Insurance will have contracted providers, which includes Medical or professional providers, Behavioral Health providers, Chiropractors, and facilities like institutional, urgent care facilities to provide services to clients.

In-Network Providers:

In-network providers will accept the clients from insurance with their active patient plan. Post patient services are provided and claims are submitted by in-network providers will be paid with as per agreed payment terms. Once a provider is approved as an in-network provider. The provider will get all in-network benefits.

Out of Network Providers:

Out of network providers are simply those who are not contracted with the payer. Healthcare provider is not contracted with payer and patient visit the provider’s locations then the provider will be termed as out of network provider. Insurance may or may not cover entire fee payment that depends on member plan. Clients may have to pay higher client responsibility when they visit out of network providers.

Fee Schedule Management:

The fee schedule is a process of the complete list of fees as per Medicare guidelines to pay Healthcare providers or supplies. Fee Schedule would be applicable for all Commercial and Federal payers as a base to negotiate with service providers to bring them as part of their network.

CMS (Center for Medicare and Medicaid Services) develops a fee schedule for Medical provider and Behavioral health care providers and also facilities and other services.

Fee Schedule is formed from the following rates and codes are formed by insurances which reimburse the provider claims.

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