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What Are the Next Steps After I Am Credentialed?

medtrust on March 26, 2025

What Are the Next Steps After I Am Credentialed?

What Are the Next Steps After I Am Credentialed?

Once you have successfully completed the credentialing process, the next steps include:

  • Registering with a practice management system to streamline your administrative processes and improve patient care. Key steps and considerations for registering with practice management software include:
    • Assessing your Needs: Determine the specific features your practice requires, such as patient demographics capture, appointment scheduling, insurance eligibility checks, and billing capabilities.
    • Integrating Your Capabilities: Choose a system that can seamlessly integrate with your existing Electronic Health Record (EHR) and billing systems to ensure efficient data flow.
    • User-Friendly Design: Opt for a system with an intuitive interface to minimize training time and improve staff adoption.
  • Submitting an Electronic Funds Transfer (EFT) request to ensure you receive payments directly to your bank account.
  • Registering to Electronic Remittance Advice (ERA) to ensure you receive payment confirmations and/or claim denials.
  • Register for provider portals for each insurance panel.

These steps are crucial in streamlining your billing process and ensuring timely reimbursements.

When Does Re-Credentialing Occur?

Re-credentialing is required every three to five years depending on the insurance panel. This process ensures that your credentials remain up-to-date and compliant with insurance panel requirements. Failing to complete re-credentialing can result in delays or loss of in-network status, so it’s important to stay on top of any associated deadlines.

Navigating the insurance credentialing process can be overwhelming, but you don’t have to do it alone. MedTrust specializes in handling all aspects of credentialing, from initial applications to re-credentialing and beyond. Our team is committed to making the process as seamless as possible, so you can focus on what matters most—providing quality care to your patients.

Let the team of experts at MedTrust help you navigate the credentialing process and set your practice up for success. If you have questions or need assistance with your credentialing, contact MedTrust today. We’d love to help you every step of the way!

Navigating the Medical Credentialing Process: FAQs Answered

medtrust on March 3, 2025

Navigating the Medical Credentialing Process: FAQs Answered

Navigating the Medical Credentialing Process: FAQs Answered

The healthcare industry can be complex, especially when it comes to insurance credentialing. Whether you’re an independent practitioner or starting your own healthcare practice, understanding the credentialing process is essential to getting reimbursed for services. At MedTrust Provider Advocates, we simplify this process for you. Below, we answer some frequently asked questions about credentialing and working with insurance companies.

What’s Included in Credentialing?

Credentialing involves verifying multiple aspects of a provider’s qualifications, including:

  • Education and Training: Verifying degrees, residency, and relevant training
  • Licensure: Ensuring the provider is licensed to practice
  • Experience: Reviewing the provider’s clinical practice history
  • Criminal Background: Conducting a background check
  • Malpractice Claims: Checking past malpractice cases and other risk factors

Why Is Credentialing Important?

Credentialing is crucial because it ensures:

  • Patients receive care from qualified professionals
  • Maintaining Quality Standards by validating educational background and professional experience.
  • Regulatory Compliance to avoid legal consequences and ensure proper reimbursement for services
  • Healthcare providers can accept third-party reimbursements from insurance companies. 

Who’s Involved in Credentialing?

  • Healthcare Providers: Responsible for submitting the required documentation
  • Credentialing Organizations: Responsible for verifying submitted information
  • National Agencies: Oversee credentialing standards to maintain quality care

Do I Need an EIN or Can I Apply with My SSN?

One of the most common questions we receive is whether a provider must have an Employer Identification Number (EIN) to apply for credentialing. The good news is that you can apply under either an EIN or your Social Security Number (SSN). However, establishing a business entity and using an EIN provides certain tax advantages and can also help protect you from individual liability.

Can I Bill Clients and Still Get Paid if I Am Not In-Network with an Insurance Panel?

Yes, you can bill clients and get paid if you are an out-of-network provider. As an out-of-network provider, you can provide the patient with a superbill that they can submit directly to the insurance company. Alternatively, you can file claims directly with the insurance company, but this will likely result in an out-of-network deductible that you will have to collect from your patient. Once the patient’s deductible has been satisfied, you’ll be able to get reimbursed by the insurance company at the out-of-network rate.

What Fees Are Required by the Insurance Company to Set Up Credentialing?

The good news is there are no fees associated with getting credentialed with a private insurance company. Governmental insurance programs, such as Medicaid and Medicare, may have specific state-based fees which depend on the type of panel and the state in which you practice. It’s best to check with your state’s guidelines or consult with our team at MedTrust Provider Advocates for precise details.

How Much Do Companies Charge for Credentialing?

Credentialing costs can range anywhere from $100 to $500 per provider per panel. A panel refers to each insurance company and it’s for each individual provider. Remember, you get what you pay for—lower fees may not always provide the best service.

How Much Does MedTrust Charge for Credentialing?

MedTrust offers competitive, flexible pricing based on which panels you apply for and the number of providers you need to have credentialed. The cost is variable and depends on the complexity of your credentialing needs. Since every provider’s situation is unique, we encourage you to contact us for a personalized quote. Our team is always ready to assist you.

How Much Does CAQH Credentialing Cost?

The CAQH (Council for Affordable Quality Healthcare) system is used by many insurance companies to streamline the credentialing and provider enrollment processes and is offered at no cost to you.

What Are Three of the Most Common Items Considered Unprofessional Conduct by State Medical Practice Acts?

  1. Malpractice claims
  2. Arrest records
  3. High debt, bankruptcy, or back child support (for Medicare/Medicaid credentialing)

How Long Does It Take to Get Credentialed with Texas Medicaid?

The credentialing process with Texas Medicaid typically takes between 100-180 days.

What Is the Most Rigorous Form of Credentialing?

Facility credentialing is considered the most challenging form of credentialing and applies to hospitals and outpatient facilities. This involves credentialing the facility itself as an umbrella for a number of providers to work under.

How Do I Contact BCBSTX Credentialing?

Blue Cross Blue Shield of Texas (BCBSTX) often directs inquiries to their web portal. A good starting point is to check their website under the contact section for credentialing support.

The Importance of Efficient Healthcare Credentialing

medtrust on February 9, 2025

The Importance of Efficient Healthcare Credentialing

The Importance of Efficient Healthcare Credentialing

Efficient healthcare credentialing is crucial for ensuring patient safety, maintaining organizational integrity, and upholding regulatory compliance in the healthcare field. This process verifies the qualifications, training, and experience of healthcare professionals, thereby mitigating risks associated with incompetent practitioners.

Efficient healthcare credentialing is crucial for several reasons:

  • Patient Safety: It ensures that healthcare providers are qualified and competent to deliver care, minimizing the risk of errors.
  • Revenue Cycle: Reduces claim denials and speeds up reimbursements, improving the financial health of healthcare organizations.
  • Compliance: Helps healthcare facilities adhere to regulatory standards and avoid legal issues.
  • Provider Satisfaction: Streamlines the onboarding process for new providers, improving their experience and satisfaction.
  • Reputation: Enhances the reputation of healthcare organizations by demonstrating their commitment to quality care.

Inefficient credentialing can lead to significant delays, increased costs, and potential risks to patient safety. It is therefore essential for healthcare organizations to prioritize and optimize their credentialing processes.

Key strategies and best practices to streamline and optimize the credentialing process:

Embrace Technology and Automation:

    • Credentialing Software: Invest in dedicated credentialing software or platforms that automate many manual tasks, such as data entry, document management, and verification processes. These systems can significantly reduce processing time and minimize errors.
    • Electronic Data Interchange (EDI): Utilize EDI for exchanging credentialing information electronically with payers and other entities, eliminating the need for paper-based processes and speeding up communication.
    • Automated Verification Services: Leverage automated services that connect directly with primary sources (e.g., medical schools, licensing boards) to verify provider credentials quickly and accurately.

Centralize and Standardize Processes:

    • Centralized Credentialing Database: Maintain a centralized database to store and manage all provider credentialing information, ensuring data consistency and accessibility.
    • Standardized Forms and Procedures: Develop standardized forms and procedures for credentialing applications and verification processes to minimize confusion and streamline workflow.
    • Delegated Credentialing: Consider delegating credentialing responsibilities to a dedicated team or individual to ensure consistency and efficiency.

Optimize Primary Source Verification:

    • Direct Communication: Establish direct communication channels with primary sources to expedite verification requests and reduce turnaround time.
    • Online Verification Tools: Utilize online verification tools provided by licensing boards, medical schools, and other credentialing bodies to quickly confirm provider credentials.
    • Document Tracking: Implement a robust document tracking system to monitor the status of verification requests and ensure timely completion.

Proactive Communication and Follow-up:

    • Clear Communication: Maintain clear and consistent communication with providers throughout the credentialing process, providing updates and addressing any questions or concerns.
    • Timely Follow-up: Conduct timely follow-up on verification requests and pending applications to prevent delays and ensure a smooth process.
    • Automated Reminders: Use automated reminders to notify providers of upcoming deadlines and required documentation.

Continuous Improvement and Monitoring:

    • Performance Metrics: Track key performance indicators (KPIs) related to credentialing turnaround time, accuracy, and provider satisfaction to identify areas for improvement.
    • Regular Audits: Conduct regular audits of credentialing processes and documentation to ensure compliance with regulatory requirements and organizational standards.
    • Feedback Mechanisms: Establish feedback mechanisms to gather input from providers and staff on ways to enhance the credentialing experience.

By implementing these strategies, healthcare organizations can achieve efficient credentialing processes, reduce administrative burden, and ensure that qualified providers are available to deliver timely and high-quality patient care.

Fee Schedules and Authorization Requirements for 2025

medtrust on January 20, 2025

Fee Schedules and Authorization Requirements for 2025

Fee Schedules and Authorization Requirements for 2025

Several changes to healthcare provider fee schedules and authorization requirements are set to take effect in 2025:

Medicare Physician Fee Schedule:

  • The 2025 Medicare conversion factor will be $32.35, a 2.83% decrease from $33.29 in 2024
  • This reduction is due to budget neutrality requirements and expiration of temporary relief enacted by Congress
  • Overall reimbursement for cardiovascular services is projected to remain flat compared to 2024

UnitedHealthcare Changes:

For Medicare Advantage plans, UnitedHealthcare is implementing new prior authorization requirements effective January 1, 2025

Delayed care and preventive services

Deductibles also influence how patients use healthcare services. Patients tend to delay or forgo care, including preventive services, when facing high deductibles. This can lead to more severe health issues down the road, potentially impacting a provider’s ability to deliver timely and effective care.

Financial risks for providers

As patients become responsible for larger portions of their healthcare costs, providers face increased financial risks. They may struggle to collect payments from patients who cannot afford their deductibles, affecting the providers’ revenue stream. Given the potential financial burden of high deductibles, providers may need to offer payment plans to help patients manage their healthcare costs and receive the care they need.

Shift in service utilization patterns

Demand for services tends to slacken across the board during the deductible phase, including both preventive care and expensive tests. This shift can impact providers’ workflow and resource allocation.

Authorization Requirements:

  • Superior HealthPlan outlines specific documentation required for prior authorization requests, including member information, provider details, service codes, and clinical justification
  • CMS established a nationwide prior authorization process for certain hospital outpatient department services

Other Notable Changes

  • CMS will allow payment for code G2211 in some situations when modifier 25 is used with certain preventive services
  • Six new optional Merit-based Incentive Payment System Value Pathways will be available for reporting in 2025
  • For Medicare Shared Savings Program, CMS finalized policies to mitigate the impact of anomalous billing activity
  • Safety planning interventions: HCPCS code G0560 for 20-minute increments of safety planning for patients in crisis
  • Post-discharge follow-up: HCPCS code G0544 for monthly billing of post-discharge follow-up contacts with patients discharged from emergency departments after crisis encounters
  • Advanced Primary Care Model (APCM) codes: New codes to recognize and reward primary care physicians providing comprehensive care, including behavioral health services

Increased focus on behavioral health integration:

  • Enhanced reimbursement for behavioral health services, particularly those related to substance use disorders
  • Emphasis on integrating behavioral health into primary care settings
  • Telehealth expansion: CMS will preserve and expand the scope of and access to telehealth services for behavioral health

Specific fee examples (for licensed psychologists):

  • Psychiatric Diagnostic Evaluation without Medical Services: $131.16
  • Psychotherapy, 30 min: $61.63
  • Psychotherapy, 45 min: $109.04
  • Psychotherapy, 60 min: $131.16

Healthcare providers should review these changes carefully and prepare for potential impacts on reimbursement and administrative processes in the coming year.

New Year Deductibles – What to Know

medtrust on January 8, 2025

New Year Deductibles – What to Know

New Year Deductibles - What to Know

Healthcare insurance deductibles have significant effects on providers as the new year begins. Providers should be well-informed to effectively manage patient care and billing processes. Here’s what providers should know about healthcare insurance deductibles and the significant effects they have on providers as the new year begins:

Reduced patient visits and demand for services

High deductible health plans reduce overall employee health care spending by 12-14% annually, primarily due to patients reducing their demand for services. This decrease in utilization affects providers’ patient volume and revenue, especially early in the year when deductibles reset.  For example, if a patient has a $5,000 deductible, they will need to pay the first $5,000 of covered medical expenses before their insurance starts paying.

Delayed care and preventive services

Deductibles also influence how patients use healthcare services. Patients tend to delay or forgo care, including preventive services, when facing high deductibles. This can lead to more severe health issues down the road, potentially impacting a provider’s ability to deliver timely and effective care.

Financial risks for providers
As patients become responsible for larger portions of their healthcare costs, providers face increased financial risks. They may struggle to collect payments from patients who cannot afford their deductibles, affecting the providers’ revenue stream. Given the potential financial burden of high deductibles, providers may need to offer payment plans to help patients manage their healthcare costs and receive the care they need.

Shift in service utilization patterns

Demand for services tends to slacken across the board during the deductible phase, including both preventive care and expensive tests. This shift can impact providers’ workflow and resource allocation.

Increased need for cost discussions

According to the Physicians Advocacy Group (PAI), 79% of physicians believe high deductibles are a key driver of patients’ cost concerns. Providers must be prepared to have more frequent discussions about costs and treatment options with patients.

Communication with Patients

Clear communication about deductibles is essential. Providers should be prepared to explain:

  • The current status of a patient’s deductible
  • How the deductible affects the cost of proposed treatments or procedures
  • The difference between the deductible and other out-of-pocket costs like copayments and coinsurance

Administrative burden
High-deductible health plans can increase the administrative burden on providers, as they may need to spend more time explaining costs, billing, and collecting payments directly from patients.

Conclusion

By having a clear understanding of the effects of high-deductible health plans, providers can better position themselves for the associated challenges as the new year begins and deductibles reset. Providers should be ready to adapt their practices to mitigate negative impacts on patient care and financial stability.

Organizing Year-End Paperwork

medtrust on December 18, 2024

Organizing Year-End Paperwork

Organizing Year-End Paperwork

Getting your business ready for tax time is a crucial step that can significantly impact your financial health and compliance with the law. As a business owner, understanding your tax obligations and preparing for them can feel overwhelming. However, with the right approach and knowledge, you can navigate this process smoothly.

Get Paid and Send Reminders

Make sure you have no unpaid invoices waiting to be sent out. If you do, don’t wait any longer. If you have insurance companies or patients who haven’t paid their invoices yet, begin the follow-up process right away.

Record All Expenses

Close out your practice’s financial year by making sure you’ve properly recorded and updated all your income and expenses. Falling behind on recording or categorizing expenses can make the new year messier than it needs to be and can lead to undesirable surprises down the line. 

Properly recording all expenses in your accounting software will keep your numbers accurate. It’ll also help your CPA find all your tax-deductible expenses easily when they assist you.

Pay Any Outstanding Invoices

While making sure your practice is receiving payments, you should also confirm that all your unpaid vendor debts, bills and employee payments are squared away before the new year.

Consider Annual Bonuses

A bonus not only shows your appreciation for your hardworking employees but also boosts morale going into the new year. Additionally, if you pay out your annual bonuses before December 31, the IRS considers them a deductible expense which will lower your taxable income. 

Purchase Medical and Office Equipment

If you’ve been eyeing some new medical or office equipment for your healthcare practice, now might be the time to buy. Purchasing qualifying equipment and implementing it before the end of the year can allow you to expense the cost up to a certain amount. 

Plus, end-of-the-year sales make it easy to find just the right price for your clinic.

Verify Employee Information

Verify past and current employee contact information and send out W-2s and 1099s to avoid unnecessary delays in the delivery of these important documents.

Review Compliance Materials

The end of the year is also a good time to review and update HIPAA policies and training programs. It’s essential to regularly review all corporate documents and agreements to ensure your healthcare practice maintains ongoing compliance with state and federal healthcare laws. 

Practices should also confirm that they’re up to date with their third-party contracts — especially with third parties who might access practice or patient records. Now is also a smart time to schedule updated privacy and compliance training for staff.

Review and Update Employee Policy Manual

Review your practice’s employee policy manual, and then update it as needed. Practices should make sure the policy manual addresses any new or modified requirements for existing and new hires.

Conclusion

Diligent record-keeping, understanding deductible expenses, and knowing your filing requirements are vital components of your tax preparation strategy. By proactively organizing your financial documents and consulting with a tax professional, you can ensure that you meet all necessary deadlines, take advantage of available deductions and ultimately set your business up for success in the new year.

Can We Fix the Healthcare Insurance Industry?

medtrust on November 23, 2024

Can We Fix the Healthcare Insurance Industry?

Can We Fix the Healthcare Insurance Industry?

The United States of America is the largest country in the world without a universal healthcare system. Our system instead relies on a combination of private insurance, employer sponsored plans and government programs such as Medicare and Medicaid. This hodgepodge creates significant challenges for patients and healthcare providers. Below is a discussion of current issues and potential fixes.

Current Challenges

Inadequate Coverage – Many Americans still lack comprehensive health insurance coverage, leading to increased medical debt and poorer health outcomes. The uninsured and underinsured often delay seeking care until their conditions worsen, resulting in higher costs and negative health outcomes.

Complex and Costly Insurance Plans – Insurance policies are often intricate and difficult to navigate, leading to confusion and unexpected expenses for patients. High-deductible plans and “skinny” health plans with limited benefits push more costs onto patients, many of whom cannot afford the required out-of-pocket expenses.

Fragmented System – The U.S. healthcare system is highly fragmented, with separate systems for the elderly, the poor, veterans, and those with private insurance. This patchwork approach leads to inefficiencies and gaps in coverage.

Potential Solutions

Expand Coverage

  1. Ensure adequate funding for the Children’s Health Insurance Program and expand Medicaid in more states.
  2. Stabilize individual insurance marketplaces and retain Affordable Care Act (ACA) market reforms.

Explore state-level innovations such as individual mandates, auto-enrollment, and reinsurance programs.

Improve Affordability

  1. Expand eligibility for premium tax credits and enhance credits for young adults.
  2. Establish a permanent federal reinsurance program to help stabilize premiums.
  3. Address rising prescription drug costs through more competitive pricing.

Enhance Transparency and Efficiency

  1. Implement greater transparency in medical billing to reduce unexpected costs.
  2. Reduce administrative waste and unnecessary procedures.
  3. Explore alternative models like Direct Primary Care (DPC) to lower costs and improve care.

Reform Insurance Practices

  1. Restrict the sale of high-deductible health plans to those who can afford the associated cost-sharing.
  2. Prohibit or limit the sale of short-term, limited-duration plans and health sharing ministry products that offer inadequate coverage.
  3. Lower maximum out-of-pocket cost limits.

Systemic Changes

  1. Move towards a patient-centered system organized around patient needs rather than physician specialties.
  2. Focus on achieving the best outcomes at the lowest cost, rather than on the volume of services provided.
  3. Concentrate services for particular medical conditions in specialized health-delivery organizations.

Conclusion

Unless and until a universal healthcare system is adopted in the United States, fixing the healthcare insurance industry will require a multifaceted approach that addresses coverage gaps, affordability, transparency, and systemic inefficiencies. While challenges remain, implementing these solutions could significantly improve access to quality healthcare for all Americans. It’s crucial for policymakers, healthcare providers, and insurers to work together to create a more equitable and efficient healthcare system.

Complex to Streamlined

medtrust on October 28, 2024

Streamlining the credentialing process can significantly reduce stress and improve efficiency for healthcare providers. Below are some key strategies designed to simplify and optimize the credentialing process to keep it as stress-free as possible.

Let us be your advocate and your guide.

MedTrust Provider Advocates is on a mission to transform the business of healthcare. We envision a world where healthcare works for everyone; providers are honored for their expertise, medical staff are celebrated for their dedication and patients are well-cared for, and the administrative burden of modern day healthcare is alleviated.
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