Physician Credentialing- Worth Getting Right to Get Paid
                     
Physician Credentialing: Worth Getting Right to Get Paid
Physician Credentialing
Physician credentialing is the process of organizing and verifying the professional records that qualify a doctor 
to practice medicine. As physicians, despite your reputation for benchmarked medical services, you could be 
losing out when it comes to realizing medical bills reimbursed fully by respective health insurance carriers. And 
when you start to analyze that elusive reason responsible for hampering your reimbursements, you invariably 
end up discovering ‘Credentialing’ as the chief culprit.
Quite a contrast to the earlier scenario, wherein your credential as a qualified and competent practitioner could 
alone determine your practice’s sustenance and growth, the present-day scenario, characterized by innumerous 
practitioners and a heterogeneous mix of insurance carriers, requires your practices to bear the stamp of 
‘Credentialing’ to stay well clear of audit, delay or denial exposures.
Although physician practices are required to be credentialed by Federal Health Agencies as well as Medicare 
and Medicaid, and respective private insurance carriers, it is the latter that assumes greater significance as it 
has a direct impact on operational optimization and revenue maximization.
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Physician Credentialing: Worth Getting Right to Get Paid
Credentialing in the medical billing context means that your medical practices are compliant with the 
benchmarked clinical and operational practices as deemed suitable by the prevailing health insurance 
convention.
As we stand at an important juncture when the health insurance sector is realigning its revenue structure after 
the Federal Government’s radical healthcare reforms, there is a growing emphasis being laid on Credentialing, 
first by the Centre for Medical Services, and then by private insurance carriers – making it mandatory for 
physicians to have their practices duly Credentialed.
But, owing to its exhaustive process, Credentialing itself could be one of your major preoccupations, relegating 
the all-important medical practice to the second! Here is the series of processes that would invariably have to 
clear to be eligible for Credentialing:
• Preparation of paper CMS 855 & other Managed Care applications for all payers
• Preparation and submission of online applications to federal and non-government carriers
• New provider affiliations and Group Contracts
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Physician Credentialing: Worth Getting Right to Get Paid
• Maintaining and updating specific Provider information directly with carriers at frequent intervals or when 
requested
• Resolving enrollment issues and tracking Managed Care contracts
• Validating information provided by payers
• Handling Provider letter of interest & enrollment transactions
• The setting of Provider information in the Practice System
• Obtaining Contracted Fee Schedules and negotiating changes
• Preparation of contracting documents for scanning and long-term storage electronically
• Preparing, maintaining, and monitoring Managed Care Summaries that provide effective dates, Fee 
Schedule details, and Group affiliation.
• Monitoring Expiry dates for NYS registrations, DEAs, and CLIA registrations and also handling re-applications 
for the same.
• Handling Re-Credentialing whenever required
• But, because of its inevitability and the incidental benefits that come with well-documented Credentialing, it 
is prudent that you outsource from competent and proven medical billing companies that can offer quality 
services at a more economical cost than it would cost if it is done internally. 
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Physician Credentialing: Worth Getting Right to Get Paid
The following overriding advantages should amply justify the efficacy of going for outsourced Credentialing:
• Insurance carriers pay better to the physicians who are on par with the insurance
• Credentialed physicians are considered reliable providers and are listed in the ‘preferred physicians group’ 
from which patients usually select their physicians in order to get maximum benefits and avoid ‘out-of-
pocket expenses’.
• Since physician credentialing involves a complete background check on providers’ educational qualifications, 
professional licenses, experience, fellowship programs, and residence, it helps in controlling healthcare 
fraud-related crimes and ensures that only qualified physicians deliver services to patients thereby 
improving the quality of healthcare in the US
• Credentialing offers comprehensive access to the fee schedule, which aids in knowing in advance the exact 
quantum of medical billing for diverse medical practices rendered.
• Credentialing is also an accelerator of strategic clinical networks and market expansion as your practices 
begin to command unprecedented goodwill in the medical fraternity.
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Physician Credentialing: Worth Getting Right to Get Paid
We, Medical Billers and Coders (MBC) – known for offering imperial Credentialing, both as an individual 
component as well as an integral part of our comprehensive suite for Medical Billing 
Revenue Cycle Management – should be your preferred choice for “Outsourced Credentialing”. To know how 
our credentialing and enrollment services can assist in increasing your practice collections, contact us at 
[email protected]/ 888-357-3226.
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