Credentailing

Hospital Credentialing: What to Expect as a Physician

It doesn’t matter whether you work in private practice or work for a hospital group. Almost every physician has to go through credentialing and privileging at some point in their career. These two terms are used interchangeably in the medical community, but do you know what they mean? Do you know what they’re for or what it takes to get approval? Credentialing and privileging take place after you’ve received licensure. Without your medical license, you will not be able to get credentialed or obtain privileges. Keep reading to learn all about hospital credentialing and what to expect as a physician.

Credentialing and Privileging: What Are They?

Credentialing and privileging are crucial to physicians in every specialty. From primary care physicians to cardiologists, almost every doctor will need both.

But what’s the difference between the two?

Credentialing 

Credentialing is the process that verifies a physician’s credentials. It is a way to confirm that the physician graduated from medical school and received their certification. Credentialing also ensures that a physician has a license to practice medicine in their specialty and their state.

Ultimately, it is a way to ensure patient safety. How? Because it prevents hospitals and practices from hiring just anyone. You cannot pretend to be a physician and get hired to practice medicine. The credentialing process makes that impossible.

Credentialing is the first step in gaining employment as a physician. It is also a prerequisite for obtaining privileges. Physicians must go through the process of credentialing before they can apply for hospital privileges.

Privileging 

Privileging, on the other hand, is a slightly different process with a very different purpose. This process centers on the physician’s scope of practice explicitly related to patient care. Depending on the type of patient care you provide, you may need different kinds of privileges.

Some physicians may qualify for all, for some, or none at all.

There are three main types of privileges:

  • Admitting privileges
  • Courtesy privileges
  • Surgical privileges

What Are Admitting Privileges?

Admitting privileges allow primary care physicians the ability to admit a patient in their care into a hospital. Sometimes referred to as “active privileges,” this type of privilege allows a doctor to work as a member of a hospital’s medical staff on occasion.

With admitting privileges, physicians can admit their patients directly to the hospital without going to the ER first. Instead, the physician usually only needs to make a phone call and fill out a few forms for their patient to get admitted into the hospital.

However, with the creation of the hospitalist role, admitting privileges for primary care physicians are on the decline. Hospitalists must admit patients with the most significant medical needs first. They make the ultimate determination of who gets admitted and in what order.

Having admitting privileges does not mean that your patients will get any preferential treatment. Privileges alone will not get them admitted ahead of patients with more immediate medical concerns.

What Are Courtesy Privileges?

Courtesy privileges work very differently. These allow physicians to admit patients on occasion or visit admitted patients regarding their general medical care.

If one of your patients gets admitted into a hospital, courtesy privileges allow you to visit that patient but not treat them. Courtesy privileges show that you have an association with the hospital. They do not mean that you can treat patients on the premises.

What Are Surgical Privileges?

If you’re a surgeon, you’ll want to secure your surgical privileges. Physicians with surgical privileges can perform outpatient surgeries and use the hospital’s operating room.

Surgical privileges aren’t limited to hospitals. They are also required to work in surgical centers and a host of other medical facilities.

Do Credentialing and Privileging Go Hand in Hand?

The answer is yes, and no.

You can get credentialed without having privileges. But you cannot obtain privileges without going through the credentialing process first.

All physicians need credentialing to practice. Privileges, on the other hand, permit physicians to treat and perform specific procedures on patients.

Without those privileges, physicians cannot provide any in-hospital services to patients.

Why is Credentialing So Important?

Credentialing is the healthcare industry’s best way to protect patients. It is a way to ensure that patients receive high-quality care from physicians who have met state licensure and certification requirements.

But what about physicians that own their practice? Do you need to be credentialed if you don’t work for a hospital or another doctor’s practice?

If you want to accept health insurance from patients, the answer is yes.

Insurance companies will not pay claims unless the physician is already credentialed. Like hospitals and large healthcare groups, insurance companies use credentialing. It is another way for insurance companies to make sure that they are paying legitimate, licensed physicians.

Credentialing is a requirement if you wish to bill through Medicare and Medicaid.

Through credentialing, health groups verify that you have completed your medical training. They do this by looking at your diplomas, licenses, and certifications.

They also look to see if you have any pending medical violations.

Physicians will have to undergo credentialing many times throughout their careers. It is common for hospitals and healthcare organizations to re-credential every two years.

Keep in mind, credentialing isn’t just for physicians working in hospitals. Almost every healthcare facility, urgent care clinic, and long-term care facility requires credentialing.

There are a variety of third-party agencies and services that handle physician credentialing. However, members of the hospital staff themselves do not do it.

Why is Privileging So Important?

Privileging ensures that a physician has experience and competency in their specialty or area of medicine. Without privileges, you cannot treat patients in a hospital setting.

Various members of your hospital’s medical staff, sometimes called an Executive Committee or Credentials Committee, would decide if you qualify for privileges. And that’s because the hospital has to answer to accreditation bodies like The Joint Commission or The National Committee for Quality Assurance.

The Joint Commission is a not-for-profit agency that defines the standard for patient care and hospital practices. It requires hospitals to grant privileges to any physician who wants to treat patients in that particular hospital.

Privileging is a requirement of Medicare, Medicaid, and most state governments. For Medicare and Medicaid patients to seek treatment at a hospital, it must have accreditation with the Joint Commission. And the way to maintain accreditation is to ensure that physicians have privileges to practice there.

Like credentialing, physicians will have to go through the privileging process multiple times. New physicians will quickly learn that this is something you’ll need to do every few years.

The Joint Commission requires that physician privileges be renewed every two years (three years in the state of Illinois).

Hospitals and healthcare organizations always have the prerogative to deny or limit privileges. The medical staff bylaws of your hospital will stipulate the timeframe in which your application will be approved or denied.

If you don’t qualify for privileges at one hospital, you may still be eligible for them at a different hospital.

As an independent physician in private practice, you may decide to seek privileges at one hospital or several. However, if you are an employee of a specific hospital, you will only need to seek privileges for that particular location.

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Provider Contracting

Understanding Your Provider Contract Fully

Provider Enrollment (Initial and Re-credentialing) – this is the process of enrolling a group or a provider with the insurance payers, also called payer enrollment or credentialing. It can often be a lengthy process depending on the payer and can sometimes take about 4 -6 months to complete. Providers typically do not have the time to follow up or respond to requests from the payers.

Often the payers end up closing the application because the providers did not respond to their requests promptly. So we, as a Provider Enrollment and Credentialing Company, take that burden off of them. We submit the applications and follow up with the payers every two weeks to make sure everything is still in process and that they are not waiting on any documentation that could slow the process down. We provide our clients with a weekly summary every Friday, so they always know where they are in the process.

Why you need to Understand your Provider Contract Fully: 

To receive reimbursement for medical services, providers depend on provider contracts in healthcare. The Contract features all of the information that needs to be collected by physicians from their patients before sending a claim for reimbursement to the payer.

Reimbursement or refund can be delayed or even denied if the claim procedures don’t strictly follow the guidelines set up in the provider contract. To ensure correct claim procedures and a steady revenue flow, here are a few essential details that are outlined in any Provider contract:  

  • Rates for billed medical services 
  • The time frame within which the health care provider must submit a claim for reimbursement 
  • The time frame within which the payer must reimburse the provider once a claim is received 
  • Scope and type of health care services that the payer covers 
  • The procedure by which the provider can dispute a claim denial  
  • How many days either party must notify the other before terminating the Contract

Mistakes or missteps in these processes can be a massive setback in setting up your Contract and may gravely cost your practice time and money.  Since you’re in the healthcare business, you know that you need to overcome several challenges.

The amount of time it takes to conduct the Provider Enrollment and Contracting can be a lengthy and time-consuming process. Provider Enrollment and Contracting with the payers are becoming more demanding and strenuous every single day. With most insurance panels getting a bulk load of work due to the burst in membership applications and a lot of them being particular about enrolling providers, the process of enrolling or registering your facility is becoming more challenging.

Under the circumstances, outsourcing your credentialing and enrollment not only looks like an attractive option to increase efficiency but also makes financial sense. Nowadays, it is a challenge to be an expert in all aspects of your industry. This is why many healthcare professionals consider outsourcing their Contracting and Provider Enrollment process to ensure quality outcomes.

Companies offering Medical Contracting Services such as Contracting Providers are trained to vet candidates, so why not leave this part of the job up to an experienced counterpart who may yield more successful results? Especially if it keeps you from the hassle and ensures you the highest quality of service. 

Our company, Contracting Providers, has helped providers with enrollment and contracting for the past 40 years, so we pride ourselves on our vast experience. We go through paperwork and know how to avoid setbacks. We specialize in the language payor groups and insurance use, helping us glide through data and rarely make mistakes.

Having dedicated personnel to watch the changing industry is a must. We pay close attention to requirement updates per state and notify you if something has changed. This is a full-time task that doesn’t allow room for error. Between using internal resources, time, and labor, expenses associated with keeping some services in-house add up. We help ongoing expenditures stay low and reduce tasks that clutter you or your staff’s to-do list.

We are constantly communicating with payor group representatives, and we have developed exclusive access to many of them. We ignore automated systems and middlemen because we have the direct line to who we need. We operate in a limited capacity – focusing on specific healthcare industry tasks – making us fast and efficient at what we do.

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Credentailing, Provider Contracting

Credentialing, Provider Enrollment, Privileging – isn’t it all the same?

Not really. While these 3 terms are often used interchangeably, they actually have different meanings:

  • Credentialing, as defined by Joint Commission, is the process of obtaining, verifying, and assessing the qualifications of a practitioner to provide care or services in or for a health care organization. During this process, which hospitals and health plans use, a provider’s education, work history, licensing, malpractice history, and more are reviewed, assuring your patients that they are receiving quality healthcare. 
  • Enrollment, also known as Provider Enrollment, is obtaining participation within a health insurance network. During this process, a request to join the network is submitted to start the application process. You will then go through the credentialing phase, and once approved, move to the final phase of enrollment, which is contracting.
  • Privileging is the process of authorizing a healthcare provider to perform a specific scope of services and procedures at a healthcare organization. During this process, a provider may go through a 2-step application process beginning with the pre-application phase to identify providers who meet minimum staff membership requirements. Once approved, they move to the application phase, which includes credentialing. When all of the information has been verified by medical staff services, recommendations are made regarding your appointment and privileges, presented to the Medical Executive Committee for final approval and granting of privileges.

Mistakes or missteps in either of these processes can be a massive setback in setting up these relationships and may gravely cost time and money for your practice. 

If you’re in the healthcare business, you know that you need to overcome several challenges. The amount of time it takes to conduct interim credentialing and full medical credentialing can be a lengthy and time-consuming process.

Nowadays, it is a challenge to be an expert in all aspects of your industry. This is why many healthcare professionals consider outsourcing the process of Credentialing and Provider Enrollment to ensure quality outcomes. Companies offering Medical Credentialing Services such as Contracting Providers are trained to vet candidates, so why not leave this part of the job up to an experienced counterpart who may yield more successful results? Especially if it keeps you from the hassle and ensures you the highest quality of service. 

Let’s take a look at the top 5 reasons why healthcare professionals consider Outsourcing the Credentialing Process;

  • Collecting Documents

Healthcare professionals like physicians have a lot going on, and they tend to misplace documents from time-to-time. These documents may include copies of licenses held, malpractice insurance face sheets, and sometimes even their diplomas. Gathering all these documents can be very tedious, and quite frankly, no one wants to do it. Hiring Contracting Providers, an experienced Medical Credentialing company with the expertise in getting these types of documents, can save a tremendous amount of time in the locum’s background check process. Our experts know precisely how to get these lost documents and replace them as quickly as possible.

  • Licensures & Primary Source Verification

Verifying Licenses can be time-consuming, and worse, some physicians can be licensed in multiple states, and international candidates have also been licensed in foreign countries. License verification will need to be performed on each of these licenses to ensure no administrative action was ever taken against any of these licenses. Doing a thorough primary source verification on a candidate is also time-consuming. Hiring Contracting Providers, an experienced Medical Credentialing company, can reduce the time it takes to complete this process, as they know exactly where to get the primary source information. Plus, Contracting Providers typically have the necessary third-party PSV accounts already established for quicker reporting.

  • Malpractice Claim History

A malpractice claim history query will need to run against every malpractice policy the physician has ever carried. Often, many physicians do not realize how important it is to keep a copy of their malpractice face sheet. Contracting Providers can help the physician find and obtain all insurance information and obtain copies of all face sheets. Contracting Providers can then run the queries to request malpractice claims history to ensure no malpractice claims have been reported. If a malpractice claim has been reported, the credentialing company can get the necessary details from the physician and the insurance company.

  • Background Check

A national background check will be required for any locum physician. Because companies offering Medical Credentialing Services such as Contracting Providers have contracts with background companies, you can avoid the hassle of having to run the background yourself. You can communicate with Contracting Providers’ experts, the Medical Credentialing company to complete the process and sit back and wait for the results.

  • Results Delivery

Results are delivered to your agency in a neatly packaged file containing every item you will need to place this candidate into a locums contract successfully. Contracting Providers, A Medical Credentialing company will also handle hospital and payor enrollment Credentialing should you decide your agency needs to complete these items. As experts, Contracting Providers can store all of your candidates’ data in a system where you can access when needed. As a recruiter, do what you do best. Leave the vetting of candidates to the professionals at Contracting Providers. Don’t let any chance miss something that could potentially cost you a contract or your company’s reputation.

Provider credentialing and enrollment with the payers is becoming more demanding and strenuous every single day. With most insurance panels getting a bulk load of work due to the burst in membership applications and a lot of them being particular about enrolling providers, the process of enrolling or registering your facility is becoming more challenging. Under the circumstances, outsourcing your credentialing and enrollment not only looks like an attractive option to increase efficiency but also makes financial sense.

With Outsourcing, you no longer have to worry about revenue cycle leaks, for partnering with experts on credentialing will relieve your credentialing headaches and boost your reimbursements. You can say goodbye to incomplete applications and inaccurate data. Outsourcing your credentialing processes can put your mind at ease. At the same time, giving you more time in your hands to focus on what matters – your practice. 

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Credentailing

Credentialing during Covid-19; How’s it like?

Credentialing efforts should be minimally burdensome to providers while expediting their ability to care for members during this unprecedented time. That’s why we are here to share with you the Credentialing/Recredentialing Standards during COVID-19 Emergency for Health Plans according to AHCCCS. 

INITIAL CREDENTIALING 

AHCCCS maintains the requirement that all providers shall go through the provisional credentialing process (to be completed within 14 days; faster if possible); interim credentialing will be effective for up to six months, at which time full initial credentialing should be completed. AHCCCS does not want additional burden placed on providers and expects the Health Plans to support expeditious and minimally burdensome processing of providers to allow them to provide care and services during this emergency. Site audits shall not be complete during this time. Concerns expressed about meeting NCQA accreditation requirements as revised credentialing requirements implemented by AHCCCS. For details on NCQA’s credentialing requirements, please visit https://www.ncqa.org/covid/. NCQA acknowledges that meeting standards may be challenging between March-September 2020 and states that any entity pursuing accreditation may submit documentation for flexibility consideration by NCQA. Sharing the answers to Frequently Asked Questions: 

  1. Is AHCCCS willing to narrow the focus for provisional credentialing to specific provider types (e.g., PCPs)? Answer: AHCCCS will not consider different processes for different provider types. As the COVID-19 emergency evolves, it could very quickly require all specialties to support member/patient needs; therefore, all providers should be credentialed using the provisional credentialing process.
  2. Can any of the requirements be relaxed for provisional credentialing? Answer: At this time, AHCCCS is not willing to settle the interim credentialing requirements. We will continue to evaluate as the COVID-19 emergency continues.
  3. In light of the changes to the credentialing process, how should MCOs report information on the quarterly credentialing report? Answer: Suspending the deliverables at this time. MCOs do not need to submit the April or July quarterly credentialing report. 
  4. How will AHCCCS evaluate credentialing files from this time? Is there anything specific that MCOs should document? Answer: AHCCCS does not intend to pull records between March and August 2020; AHCCCS will determine if the date needs to extend after the conclusion of the COVID-19 emergency. With that said, MCOs are expecting to keep detailed notes in the credentialing files regarding timeframes.
  5. Is the expectation that MCOs process both Clean and Risk files for Provisional Credentialing? Answer: This applies to clean files only. The MCO may evaluate risk files to determine the best course of action for processing, based on the MCOs standard operating procedure and comfort with associated risk.
  6. Will AHCCCS waive the completion of Provisional credentialing within 14 days once Temps are issued within 7 days and extend the timeframe to allow for that work to be completed? Answer: At this time, AHCCCS will not change the processing time. Providers should move through credentialing approvals and load times as expeditiously as possible to avoid delays in the providers’ ability to provide services to MCO members and bill for services rendered. 
  7. What would be the extended Provisional Credentialing (once Temps are issued) timeframe allowed? Answer: Once provisional credentialing is complete, the MCO has six months to credential the provider fully. 
  8. What is the timeframe expectation for loading providers into MCO claims payment systems once temporary credentials are issued? Answer: The timeframe for loading will follow the standard 30-day requirements; however, the date must be reflective back to the date of credentialing application or AHCCCS registration (whichever occurred earliest).
  9. Is the expectation that MCOs make exceptions and credential practitioners that are not enrolled with AHCCCS? Answer: AHCCCS is expediting provider registration during the COVID-19 emergency. If the provider is in the process of AHCCCS registration, provider credentialing may run simultaneously to the AHCCCS processes.
  10. Is the expectation of loading all associated service addresses once a practitioner completes Temp credentialing? Answer: Yes, all service addresses should be loaded so that a provider does not have any issue with claims processing/payment.

RE-CREDENTIALING

AHCCCS is aware that there is a concern with the six-month extension for re-credentialing due to the misalignment with NCQA guidelines. However, due to the unprecedented pressure on providers as well as NCQA’s statement, “NCQA understands that state governors and other government officials are responding to changing conditions in their localities with COVID-19 regulation. NCQA will not penalize organizations when these regulatory responses may prevent an organization from meeting an NCQA accreditation requirement (e.g., suspension of routine communication to members and practitioners).”

AHCCCS will maintain the six-month extension. Additionally, NCQA has stated that they will not pull any files that are impacted during the COVID-19 emergency. NCQA also says that they will make state-specific assessments if the state has provided specific guidance that is not aligning with NCQA’s processes during the COVID-19 crisis.

  1. Does this apply to both Practitioners and Organizational/Facility Credentialing? Answer: Yes, the re-credentialing guidance applies to Practitioners and Organizational/ Facility credentialing.
  2. Is it AHCCCS’s intent to have MCOs focus on initial credentialing during this time? And if so, what would be an example timeline for delayed re-credentialing? Answer: Yes, MCOs should prioritize initial credentialing efforts. Re-credentialing timelines are extending by six months. Suppose a re-credentialing attempt was due in March 2020, and the provider does not have substantial quality/utilization concerns. In that case, the re-credentialing is appropriate as long as it is completed by September 2020. 

ONSITE MONITORING

  1. What is the estimated ETA on when the standardized provider attestation statement will be available for use? Answer: Due to the ongoing evolution of the COVID-19 emergency and the unprecedented strain placed on the delivery system, AHCCCS is revising previous guidance around the attestation statement. At this time, AHCCCS will not be. 
  2. Should the attestation be considered part of the credentialing file and be conducted a future site visit once onsite visits can resume? Answer: See answer above in III.1.

It is not as easy during this Global Pandemic, but it’s also not impossible. If you need help and have more questions, you may book a Free Non-Obligated Consultation with one of our experts to explore your options. Book a Free Consultation here. 

Source: AHCCCS.gov

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Credentailing, Provider Contracting

Outsourcing Credentialing and Provider Enrollment

When we meet with potential clients, some hesitate to externalize their credentialing and enrollment processes. Outsourcing, however, provides various perks and benefits that help your organization function at optimal levels, gain market share and increase profit.

Operating costs are the expenses that are associated with a business’ day-to-day maintenance and administration costs. The total operating cost for a company includes the cost of goods sold, overhead expenses, and operational expenses. The total operating cost is deducted from the gross revenue and reflected in a company’s income statement. Operating costs are typically composed of many components of operating expenses, including:

  • Rent
  • Repair and maintenance costs
  • Utilities
  • Salary and wage expenses
  • Accounting and legal fees
  • Bank charges
  • Sales and Marketing costs
  • Advertising
  • Travel expenses
  • Entertainment costs
  • Office supply costs

Operating costs are also composed of the cost of goods sold, which are the expenses directly related and tied to the production of goods and services. Some of which are:

  • Direct labor
  • Direct material costs
  • Rent of the plant or production facility
  • Benefits and wages for the production laborers
  • Repair costs of equipment and machine (if applicable)
  • Taxes of the production facilities

Companies like Contracting Providers are experts in processes like credentialing. They ensure top-quality end-to-end credentialing process management; reduces operating costs, usually around 30-40%. You may expect less to zero mistakes in your credentialing once you outsource this process to them. 

With Outsourcing, you no longer have to worry about revenue cycle leaks, for partnering with experts on credentialing will relieve your credentialing headaches and boost your reimbursements. You can say goodbye to incomplete applications and inaccurate data. Outsourcing your credentialing processes can put your mind at ease. At the same time, giving you more time in your hands to focus on what matters – your practice. 

Provider credentialing and enrollment with the payers is becoming more demanding and strenuous every single day. With most insurance panels getting a bulk load of work due to the burst in membership applications and a lot of them being particular about enrolling providers, the process of enrolling or registering your facility is becoming more challenging. Under the circumstances, outsourcing your credentialing and enrollment not only looks like an attractive option to increase efficiency but also makes financial sense.

Contracting Providers have been helping providers with enrollment and credentialing with more than 40 years of experience. We go through paperwork and know how to avoid setbacks. We specialize in the language payor groups and insurance use, helping us glide through data and rarely make mistakes. Having dedicated personnel to watch the changing industry is a must. We pay close attention to requirement updates per state and notify you if something has changed. This is a full-time task that doesn’t allow room for error.

Between using internal resources, time, and labor, expenses associated with keeping some services in-house add up. We help ongoing expenditures stay low and reduce tasks that clutter you or your staff’s to-do list. We are always communicating with payor group representatives, and we have developed exclusive access to many of them. We ignore automated systems and middlemen because we have the direct line to who we need. We operate in a limited capacity – focusing on specific healthcare industry tasks – making us fast and efficient at what we do.

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Provider Contracting

Payor Contracting for Providers

Managing payor contracts is one of the main hurdles that every healthcare provider meets. From changing reimbursements to issues accessing networks and managing hidden clauses, contracts represent a significant hurdle that affects every provider, regardless of size. This is why we wanted to share with you the process of Payor Contracting for Providers for you to assess. 

PAYOR CONTRACTING: THE CHALLENGE

For most healthcare providers, the critical problem associated with managing an extensive range of payor contracts lies in the complexity of the process. Most providers work with several different payors at once, with each contracted payor operating under their own terms. That means:

  • Variation in reimbursement schedules
  • Different rates between payors for the same or similar services
  • Wide range of network participation
  • Shifting requirements for reimbursement
  • Contract language that is confusing and unique to each payor

The disparity between payor contracts is intentional and a significant part of payor strategy. Many payors will deliberately change contract terms consistently to improve reimbursement conditions at the expense of healthcare providers. Generally speaking, this is permissible under the terms of a payor-provider contract. 

Without a centralized process for managing these contracts and tracking variations between revenue generation for each payor, healthcare providers’ ability to understand whether they are compensated relatively is limited.

As a healthcare provider navigating the complexities of the contract management revenue cycle, reference the following step-by-step to simplify reimbursement processes across payors. 

STEP-BY-STEP GUIDE TO TRACKING YOUR PAYOR CONTRACTS

Despite the difficulties associated with payor contracting, it is possible to implement an applicable system for tracking contracts across providers to ensure fair terms. But, of course, the process itself can be complex, which is why many providers opt to outsource these strategies to a third-party healthcare consulting firm.

When creating a process to track your payor contracts, the end goal is to successfully enter renegotiations with payors and achieve better terms and working knowledge in the process. 

To do so, a provider organization should go through the following four steps:

  1. Get a sense of the fine print within payor contracts.
  2. Perform a deep dive into your payor contracts.
  3. Build a centralized contract management system.
  4. Prep for negotiating managed care contracts.

Step 1: Get a Sense of the Fine Print

When providers understand the terms of their payor contracts in detail, including the fine print, you should identify terms that could put you at a disadvantage. That’s where you need to begin—providers must analyze each payor’s contract in detail. Start by getting a sense of the basics of each contract:

  • How many days does the provider have to submit a claim for a provided service?
  • How many days does the payor have to reimburse the provider for a given service?
  • What is a managed care contract, and what are the payor services covered? (Make an entire list of eligible services.) 
  • What are the rates for each service provided? 
  • How are disputes handled under the terms of the contract? 
  • What is the notice period required to negotiate new terms or terminate the contract? 

By fully understanding these requirements, providers can avoid any payment delays or inaccuracies, ensuring they enter renegotiation with each payor at the correct time. 

Step 2: Perform a Deep Dive into Payor Contracts

After initially analyzing each payor contract, it should be somewhat clear which payors provide more attractive terms. However, payor contracts contain underlying complexities that must be investigated before evaluating the contract’s overall suitability for a provider. 

To ensure the accuracy of results, providers should continue the process towards renegotiation by performing a deep dive into the language of each contract. 

Why? To protect revenue from potential pitfalls and enhance contract management, it is necessary to understand the clauses and requirements embedded completely. 

Read through each contract and identify the following clauses, assuming they are present:

  1. Unilateral Amendments – This clause enables payors to change contract terms at will, including payment rates, requirements, network participation, and contract language.  
  2. Reimbursement – These policies are not always included in contracts but must be identified. If you cannot find the reimbursement policy within a given contract, you must contact the payor and ask for a review. 
  3. Network Requirements – These clauses will list eligible provider organizations and the requirements to be part of a given network. Payors often change these requirements, potentially eliminating a provider from a network and effectively decreasing the provider’s number of eligible patients. 

Let’s dive a little deeper with each of these

Unilateral Amendments

Unilateral Amendments come with a given notice period ranging from 30 to 90 days: 

  • Providers are under no obligation to accept a period as short as 30 days, which could put them at risk of being taken advantage of by the payor.
  • Providers need ample time to review changes to contract terms, so they should not accept a unilateral amendment with a review period shorter than 60 days. 

When performing a deep dive into contract terms, make sure to pick out any payors that retain unilateral amendment rights and eliminate this option upon renegotiation. 

Reimbursement

Many payors also retain the right to change reimbursement policies at will. Both providers and payors must adhere to these stipulations. Providers who fail to operate in line with a given policy face payment reimbursement denials. 

One of the essential dynamics of proper contract management is identifying whether reimbursement policies differ across payors, including pinpointing which terms are more favorable to the provider. 

Network Requirements

Patients utilize networks to select a healthcare provider, making it essential to monitor their participation in these networks. 

In most cases, payor-provider contracts assign providers to networks based on two critical criteria:

  1. Credentialing Criteria are essential for a healthcare provider to enter into a network, such as adequate care, proper licenses, and acting according to laws and values.
  2. Additional Criteria – is added measures that can exclude many providers from networks, such as the availability of specialists on-site or specific physicians’ availability.

When reviewing contract network requirements, providers should remain aware of additional criteria. Because these requirements can be changed at the whim of the payor, providers are at risk of losing out on potential revenue by being excluded from networks for arbitrary reasons. 

Renegotiations should aim to eliminate any additional criteria from payor-provider contracts. 

Step 3: Build a Contract Management System

After completing Steps 1 and 2, providers should have a sense of which contracts provide more beneficial terms and contain underlying clauses that should be re-worked. 

Because there are various payor contracts to keep track of, providers should merge the information into an accessible, centralized contract management system that can be monitored consistently. 

  1. Contact each payor and ask for access to all contract documents, including product line specifics
  2. Implement a system to store and track each contract
  3. Create email notifications for all auto-renewals, deadlines, and provisions that go out to every relevant staff member

Over time, every provider’s goal should be to standardize contracts and make them as similar as possible while maintaining attractive terms. By building a system that tracks deadlines, providers can minimize the risk of adding unwanted provisions or renewing contracts without notifying the provider. 

Additionally, by monitoring and evaluating contracts across payors, providers can identify better terms and use them as a basis for renegotiation when ready. 

Step 4: Prep for Renegotiations

Once your team monitors contracts across payors, providers can begin prepping for renegotiation of less attractive contracts. The enhanced understanding that has been achieved in steps 1-3 acts as a basis for better payor negotiation tactics. 

How should providers approach renegotiation? 

  1. Analyze fee schedules and payments across payors and assign a rating to each payor in terms of overall benefit.
  2. Determine your revenue levels from each payor by service offering and check who pays you more and who pays you less.
  3. Considering contract values—with more significant contracts, it will be more acceptable to have lower margins and vice versa.
  4. Ask for input from executives, staff, and other key stakeholders on their experiences dealing with each payor.
  5. Decide which contracts require renegotiation and which should be renewed as is.

The result of this negotiation process should be a coherent plan to access better rates from payors that are not contributing enough and maintain contracts with payors that provide beneficial terms. 

OUTSOURCE TO ENHANCE YOUR REVENUE 

Even following the above guidance, managing payor contracts for healthcare providers can be extremely difficult. Why not consider outsourcing this process to a third-party expert who will ensure you get the best possible contract terms?

Thus, we recommend you going over to Contracting Providers to talk to experts about helping you with your Contracting needs.

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Provider Contracting

Different Healthcare Provider Contracts

As a healthcare provider, it’s essential to consider your opportunities when considering provider contracts for health care services. Unfortunately, not all provider contracts are created equal. Different types of Healthcare Provider Contracts have major differences in their payment systems that can significantly affect your revenue, the overall success of your facility, and even patient outcomes.

Each contract has its nuances and unique specifications and must be considered in an independent context before signing with a specific healthcare contract management system. With that being said, there are two general types of healthcare provider contracts for health care services you should be familiar with: 

-fee for service and 

-predetermined per-person payments.

To help you find the system that best suits your needs, this simple guide breaks down the pros and cons of all types of healthcare provider contracts.  

Fee For Service 

In a fee-for-service model, healthcare providers are paid via invoices for services rendered. In this system, each service’s cost is charged to the patient and their insurer by the provider. As a result, different services carry different price tags. In some fee-for-service cases, providers may charge patients on a sliding scale according to their income level.  

Pros of Fee For Service Contracts

  • More tests and services for patients – Because physicians are paid for every service they administer at a healthcare facility, they are more likely to offer their patients a wide range of care. The fee-for-service model incentivizes physicians to try all available treatments, leading to better patient outcomes.
  • Chance of higher revenue for providers – Medical services vary significantly in cost, and patients’ need for treatment also changes over time. It is likely that, in specific periods, a health care provider will see many patients who require many different high-cost treatments. When the health care provider sends all of those invoices to the payor, they are likely to generate more revenue.  

Cons of Fee For Service Contracts 

  • Uncertainty in revenue – For the same reason that fee for service contracts may lead to higher revenue at times, they can also contribute to unpredictability. The provider’s income is entirely dependent on how many patients they see and how many services they administer. It’s impossible to predict with 100% accuracy how much revenue the provider will generate. In other words, provider income is not guaranteed. 
  • Risk of cost overruns – More patients than expected may require care in a certain period, which will lead to more money being spent by the payor to cover the costs of services. The risk of cost overruns is entirely on the payor, as the provider is incentivized to charge for as many treatments as possible. This is a con of the fee-for-service model from the perspective of payors, making them less likely to employ it in their contracts.  

Predetermined Per-Person Payments  

In a predetermined per-person payment model, providers receive a set payment for each person assigned to their care, regardless of whether or not those patients seek medical services. This system may also be referred to as a capitation model. 

For example, a physician may be paid $50 per month for 100 people under their care ($5000). If the physician only sees 30 of their patients in January, they will still be paid $5000 for that month. 

Pros of Predetermined Per-Person Payments 

  • Financial certainty – For both providers and payors, predetermined per-person payments lead to a greater degree of predictability. The provider knows precisely how much they can expect to be paid every month, and the payor is not entirely at the risk of cost overruns as with a fee-for-service model.  
  • Easier budgeting for patients – Because costs are not tied to the specific services rendered, patients can seek medical treatment from their physicians with the confidence of knowing their expenses will not considerably fluctuate based on the kind of care they need. 

Cons of Predetermined Per-Person Payments  

  • Not being compensated for expensive treatments – Sometimes, some patients may require lots of costly treatments. Under a fee-for-service model, this would lead to much higher revenue for the provider. In a predetermined per-person payment model, when more patients than predicted fall sick and need care, providers are not compensated for that extra work.  
  • Quantity over quality – Capitation payment models have been criticized for prioritizing quantity over quality of healthcare. Providers are incentivized to add more patients to their coverage rather than to deliver the best medical treatments. Capitation has led some providers to “cherry-pick” healthy patients because unhealthy patients require more resources and services whose costs cannot be recouped in extra payment.  

Choosing the Right Type of Healthcare Provider Contract for You 

Fee for service and predetermined per-person payment models have benefits and drawbacks that must be balanced before agreeing to a provider contract management system. Plus, the payment model is only one aspect of this dense and complex business agreement.  

Fortunately, third-party contract management firms like Contracting Providers help guide providers toward contracts best suited to their needs. With Contracting Provider, you can rest assured that your provider contracts will result in higher revenue. Contracting Providers also monitors your contracts after you sign, notify you of any changes, analyze your data, and creates valuable insights about your organization’s growth. 

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Provider Contracting and Everything You Need to Know

The provider contract is a vital element for any health care provider who wishes to operate a smoothly run facility with high patient satisfaction and on-time payments. However, there are many different types of healthcare provider contracts. Each is filled with lots of unfamiliar legal jargon and confusing clauses, amendments, and stipulations. 

To get a better idea of what to expect in a provider contract and how to negotiate the most beneficial terms, follow along as we break down everything you need to know. By the end of this article, you’ll also learn the benefits of using a healthcare contract management system for your healthcare facility. 

Why You Need to Understand Your Provider Contract Fully 

To receive reimbursement for medical services, providers depend on provider contracts in healthcare. The contract details all of the information that needs to be collected by physicians from their patients before sending a claim for reimbursement to the payer. Reimbursement or refund can be delayed or even denied if the claim procedures don’t strictly follow the guidelines set up in the provider contract.

To ensure correct claim procedures and a steady revenue flow, here are a few essential details that will be outlined in any provider contract:  

  • Rates for billed medical services 
  • The time frame within which the health care provider must submit a claim for reimbursement 
  • The time frame within which the payer must reimburse the provider once a claim is received 
  • Scope and type of health care services that the payer covers 
  • The procedure by which the provider can dispute a claim denial  
  • How many days either party must notify the other before terminating the contract

How to Negotiate for Better Terms in a Provider Contract 

The first step in any successful provider contract negotiation occurs long before you reach out to the payer with demands. Prior to engaging in formal negotiations, you should arm yourself with as much knowledge as possible. Familiarize yourself with your current contract, and research the legalese to become more comfortable speaking the payer’s language. 

Then, engage in each of the following best practices. 

Gather Internal Data

Once you have mastery over the contract’s components, it’s time to gather internal data. Because most providers are contracted with multiple payers, start by reviewing your top 5 or top 10 payers. Determine your most frequently billed services and compare the payment amounts you receive from each of your top payers. With this data, you can analyze the financial performance of each provider contract. Then you can set target goals for the negotiation. 

You can also analyze your past claims to determine which payers reimburse you the least for certain health care services. With that data, you can argue in future negotiations that the payer should offer a reimbursement rate that is more in line with the rest of the marketplace. 

Survey Patient Satisfaction

Another important data point to collect is the rate and quality of patient satisfaction. Because this data has some subjective elements, you may need to rely on patient surveys. Still, positive patient surveys can demonstrate your facility’s efficiency and effectiveness. 

You can also survey other physicians who refer patients to your facility, as well as any hospital administrators you work with. Systematically surveying the people in your business landscape can provide a clear picture of your value.  

Conduct Market Research 

Think about your facility in the context of your surrounding area. Find out information on these key questions: 

  • Is there a niche service that your facility specializes in? 
  • How many other facilities in your area offer the same services as you? 
  • Do you have a good reputation among top referring physicians in your area? 
  • How does your facility compare in size to those around you?  
  • For how many residents are you the closest medical facility?  

Suppose you can demonstrate that your facility is an integral part of your community, a unique healthcare offering, and a top option for patients. In that case, you will have more leverage in contract negotiations.  

Prepare Specific Demands 

When you finally sit down to engage in proper negotiations with your payer’s representatives, you should have ample data to back up your demands. Keep in mind that your requests should be specific and evidence-based. It’s much easier for the payer to deny a general plea for better contract terms than, for example, a data-supported demand for a 5% increase to your ultrasound therapy reimbursement rate.

Contracting or being ‘in network’ is an optional relationship offered by most insurances that makes you an official ‘participant’ with that insurance. Being contracted restricts your freedom to charge and collect from patients and often involves negotiating rates with that respective insurance company. That said, being in-network means you’ll likely get a steadier patient stream because patients typically receive better coverage for in-network services.

Often providers enroll in a plan and then never review the performance of the contract. Years go by, insurers do not update your contract to reflect updated reimbursement rates. Does your biller or associated billing company periodically review contract performance and update your contracts?

The entire process of credentialing and contracting is complex and tedious. Does the staff member or biller submitting your applications understand the regulations or are they just trying to complete a form? Thousands of dollars can be lost and payments may be interrupted if there are errors or inconsistencies in your contracting and credentialing. This is entirely the reason why you need to work with a Contracting Company that can help you not only save up on time but also make sure the quality of Contract for you. A company with over 40 years of experience can do exactly that. 

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Private Practice & Insurance Billing

Healthcare providers venturing out into private practice often are unsure about establishing their procedures for third-party billing networks for services. The process of billing and reimbursement refers also called the “Revenue Cycle.” The first step in the revenue cycle is to obtain credentialing and a participating provider contract with insurance companies important to your service area. Building a successful Private Practice & Insurance Billing is complicated, but you can make the process a bit less intimidating with a bit of planning. Here are some reminders to keep you in the loop. 

Prepare for Credentialing

Credentialing is a process that the insurance companies use to verify your education, training, and professional experience and ensure that you meet their internal requirements to serve as an in-network provider on their panel. Insurance companies are required to provide web-based provider directories listing all in-network providers for their plans. These online directories are regularly used by healthcare services consumers to locate physicians and other healthcare providers who accept their insurance. Therefore, the first step in implementing your new revenue cycle is to get credentialed and contracted with the insurance plans that are important to your service area. Once complete, consumers will be able to locate you as a participating provider in their panel for your specific specialty.

The process of “credentialing” or “provider enrollment” with an insurance network consists of two phases. 1) Credentialing and 2) Contracting. The credentialing phase is when the insurance company verifies all your credentials and meets their requirements for participating in their network. The contracting phase is where the company issues you a participating provider agreement that defines the terms of participation for receiving in-network reimbursement for your claims.

Without a participating provider agreement, you will not receive in-network reimbursement. Until your credentialing and contracting are complete, you may have the option to bill the network as an out-of-network provider, but there is no guarantee of your claim being processed. Whether or not your claim is even accepted depends on if the patient’s policy has out-of-network benefits. Government health plans such as Medicare and Medicaid will not pay for any out-of-network services.

Checklist items for credentialing and contracting preparation:

  • Consider establishing a business entity under which to practice (LLC, S-Corp, PC, etc.) and obtain your tax ID
  • If operating as a sole proprietor, consider bringing a federal tax ID to operate under instead of your SSN
  • Obtain your professional liability insurance policy
  • Obtain an NPI number for you individually (type 1) and your business entity (type 2)
  • Be fully licensed in the state where you will provide services (including prescriptive authority)
  • Create a profile with CAQH and keep it current
  • Have your practice location ready
  • Know which insurance networks you want to participate with

Credentialing With Insurance Networks

The process is time-consuming. Once you have prepared for the process and know which insurance companies you want to participate with, it’s time to get started. Expect to spend anywhere from 2 – 6 hours on each application when considering application preparation and follow-up throughout the entire process. In many instances, it will make economic sense to outsource this critical revenue cycle step while you focus on treating patients or work on other business-building activities.

Many physicians and other healthcare practitioners starting a new practice who previously worked for another organization often think that since they are already in-network with an insurance company, little or nothing needs to be done for their new private practice. However, in many situations, those providers participated under the previous organization’s group contract, which will not transfer to the new private practice. Do not assume in these situations that your credentialing process will be any faster with the insurance companies. Contact each plan to determine your contract status and get instructions on setting up your new practice. Some will require you to go through the entire process from the beginning; others may have abbreviated processes to get a new private practice contract issued. If you participated with the previous organization under an individual contract, you might transfer your contract to your new private practice. The process varies widely by plan.

Checklist for beginning the process

  • Contact the network provider services department to inquire about their credentialing process and obtain a credentialing application. Most plans have applications and information on their website, such as here with Aetna.
  • Take time to fully complete your application listing all service locations for your practice, sign and date your application, and include copies of all required documents.
  • Ensure that your CAQH profile is up to date with all information, mainly practice location information, and includes copies of all required documents such as license, insurance, board certifications, etc
  • Retain a copy of your completed and submitted application.
  • Verify with the insurance company that your credentialing application was received, and follow up with the insurance network regularly until your credentialing is complete and you have an effective network date with a participating provider agreement
  • Respond to any requests for additional information that the insurance company may have
  • Document all of your follow-up activities as you go through the credentialing process.
  • Review your participating provider contract for details of your requirements as a network provider, claims submission procedures, fee schedule for your services, timely filing limits, and other essential contract terms.
  • Keep copies of all credentialing applications and contracts submitted. Be sure to retain a final copy of your network contract.

Upon Completion

When your credentialing process is complete, you are ready to begin billing the network for services. Here are a few key things to remember about maintaining your credentials:

  • Access the network website so that you can confirm you are listed in their directory. Most networks also have access to claims filing, benefits verification, claims follow-up, and other revenue cycle activities on their website.
  • Record all contact information for the insurance company related to claims filing, contracting, and credentialing.
  • Record your provider id, effective date, and when your following re-credentialing process will be due
  • Maintain copies of all your network contacts in one central location for ease of management
  • After a year of service, evaluate which networks provide patient volume and compare reimbursements to identify carriers to eliminate or renegotiate reimbursement rates.
  • Maintain your CAQH profile by quarterly attestations and document updates any time you renew an item such as license or malpractice insurance
  • Maintain your NPPES records so that your NPI numbers always reflect the accurate name, address, and other information
  • Do not neglect re-credentialing requests from plans or requests for renewed or additional documents. Failing to respond to a request can lead to a network termination.

Get in-network faster and easier on your part. Talk to one of our experts today–> Contracting Providers 

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Considerations to Private Practice

When smaller, private practices open, it means more competition and a more widespread distribution of profits throughout the industry. It also means that more healthcare providers are granted more autonomy, becoming free to determine their own workflows. Another major byproduct of increasing smaller practices is that they help expand healthcare access to local areas that might currently be underserved. These are things that can slow down or completely derail your progress leading up to the opening day or take you by surprise when you think your practice is up and running smoothly. Here are a few considerations to your Private Practice to keep in mind:

Construction needs

If you need to perform any construction on your office space, start as early as possible. Otherwise, you might find yourself well past your target opening date without a workable space. Of course, it’s always best to find a turnkey location where you can immediately set up shop, but such space is not always available. So instead, evaluate your site early on, determine what work needs to be done, and then hire the contractors who will do it. With luck and planning, construction will be complete by the time you’re ready to start purchasing equipment.

“There are so many variables if you have to do a fit-out,” Zetter said. “It’s guaranteed: Construction always delays things. Even if you start planning in January that you’ll open in June, be prepared for August [if you have to do construction].”

Changing regulations and payer rules

The healthcare industry is a highly regulated one, with complex rules surrounding virtually everything a provider does. For a small practice, which doesn’t have legions of attorneys on retainer as an extensive hospital system does, it can be challenging to navigate the web of legal requirements and payer rules. However, it is imperative to understand what it takes to comply. In addition, the rules governing the healthcare industry are constantly being changed and updated, so even if you comply today, you’ll have to keep an eye on the future.

“There are particular compliance manners for medical practices, mostly tied to government regulations, like privacy with HIPAA, and certainly being in compliance with the way you bill and treat Medicare and Medicaid patients,” Reiboldt said.

For example, HIPAA requires all healthcare IT products to abide by a particular security standard to safeguard patient data, which has become especially critical as digitization of the healthcare industry has increased, increasing the likelihood of cyberattacks. It’s your job to ensure that every product you select meets HIPAA standards.

Marketing

With all the necessary preparation for opening day, followed by the hustle and bustle of treating patients once you do open, it can be easy to forget about marketing. Yet, marketing and advertising are fundamental to starting a private medical practice as they are to a Dunkin’ Donuts franchise, particularly for general practitioners who won’t be able to rely on a referral network for their patients.

“One thing you would plan for before opening and then continuously do after opening is marketing,” Reiboldt said. “This is a patient-caring, disease-treating business, but with that said, it is a business, and a practice needs to know how to market itself.” After all, how can you be a successful practice without attracting patients?

Advisors

This guide, however informative, is certainly not exhaustive, and no amount of research can prepare you for everything that might happen as you get started. For that, you need real experience, and there are plenty of professionals who have experience in spades. Zetter, who acknowledged that perhaps it seems self-serving, said hiring a consultant with plenty of experience launching medical practices will save you money in the end and help you avoid costly and time-consuming mistakes.

“The biggest advice I can give is [to] think about who are going to be your advisors,” said Zetter. “Yes, you will spend more money, but if you do it smartly, you will set yourself up for success and spend less in the wrong. You want somebody who wants to be doing business with you 20 years from now when you’re ready to retire and sell your practice.”

Paul Inselman, a doctor and founder of the Creative Coaching medical marketing firm, listed a handful of advisors and professionals that it’s wise to retain in perpetuity:

  • Certified public accountant
  • Business attorney
  • Business coach
  • Insurance agent
  • Financial planner
  • Investment advisor

“Opening a new medical practice will be the most exhilarating and scary thing that you will ever do in your career,” Inselman said. “When we coach our clients on opening up a medical, dental, chiropractic, or any other healthcare practice, the first thing we advise is to assemble your team.”

Meaningful Use standards

The healthcare industry is undergoing digitization, primarily focused on adopting EMR and practice management software. You are now known as Promoting Interoperability; the Meaningful Use standards prescribed by the Centers for Medicare & Medicaid Services layout precisely what is expected of a medical practice’s use of an EMR system. You have to ensure that your EMR partner is capable of meeting these demands but that you implement the technology so that your medical business is functioning up to the standards. Otherwise, you could face reimbursement penalties.

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