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At ABCS RCM we submit and track insurance payments, as well as maintain credentialing requirements for a wide variety of healthcare specialties. Increasingly, we are finding that some of the newer requirements for medical credentialing are a challenge. The task of keeping medical credentials up-to-date is often too time-consuming for many health professionals.

Medical credentialing is a complex process, so it is helpful for a medical staff to have a credentialing specialist who can execute the process from start to finish. A dedicated credentialing specialist will more efficiently track re-attestation and revalidation updates. In fact, a credentialing specialist actually becomes an essential part of the healthcare team.

For example, to ensure no delays in the credentialing process, a credentialing specialist communicates directly with the medical team in order to provide key informational updates for CAQH, PECOS, NPPES, etc. This means that healthcare professionals must rely on a credentialing specialist in order to keep them informed about completed tasks and contract updates.

Health systems, as well as individual providers, must successfully manage credentialing requirements and updates. Establishing and maintaining credentialing is a critical task for any healthcare provider or health system. However, navigating through the maze of questions, applications and terminology is a challenge for many healthcare professionals.

The staff at ABCS RCM solves this problem and helps clinicians with this process. This allows a medical practice to quickly become a participating provider. Every insurance provider has their own unique guidelines and procedures, but ABCS can guide you through this complicated credentialing process.

Credentialing specialists always need to maintain open lines of communication with the medical staff, but there are still some larger credentialing challenges for many healthcare providers.

Ongoing medical credentialing challenges:

  • Facilities and practices with a higher volume of insurance claims are able to negotiate better payment rates from insurance companies, while practitioners with lower volumes may receive less competitive reimbursements from their insurance payers. Additional challenges arise from closed insurance panels with insurance providers (payers) feeling that if a specific geographical location has too many clinicians of one medical specialty, that insurance company will not allow additional providers to join their network.
  • Health providers will still need to update their CAQH information and go through the process of re-attestation once a quarter, as well as monitor Medicare’s revalidation process. Health professionals should track their compliance status and not assume that the CAQH or their Medicare Administrative Contractor (MAC) will always notify them when it is time to re-attest and/or revalidate.
  • Some healthcare professionals will have to regularly provide medical treatments that are out-of-network and receive lower reimbursements for these delivered services.
  • Practitioners must guarantee that they are receiving CAQH’s re-attestation and Medicare’s revalidation email notifications, as well as check that any HIPAA compliant email software is not delaying these notifications.

As part of the medical team, ABCS RCM is constantly focused on helping to alleviate some of the regulatory and credentialing burdens carried by healthcare professionals. However, even with increasing documentation and credentialing requirements, every health professional must remember that improving the quality of care for patients is always the primary goal.

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Medical Credentialing Challenges, Credentialing Specialist