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Credentialing, insurance panels, revalidation, etc. – these are often questions that we here at ABCS RCM receive on a regular basis. Previously, medical credentialing for healthcare providers was a fairly straight-forward process. However, obtaining medical credentialing has become an increasingly complex task. Due to this fact, healthcare practitioners should consider outsourcing this task to an agency like ABCS who specializes in the healthcare credentialing process.

For readers who are unfamiliar with the credentialing process here is a brief description from one of the major insurance providers. Humana defines medical credentialing as “the process of obtaining and reviewing documentation to determine participation status in a health plan. The documentation may include, but not be limited to, the applicant’s education, training, clinical privileges, experience, licensure, accreditation, certifications, professional liability insurance, malpractice history and professional competence. Generally, the terms credentialing and re-credentialing include the review of the information and documentation collected, as well as verification that the information is accurate and complete.”

This means that healthcare practitioners need to submit documentation to every insurance provider that they wish to receive reimbursement from as an in-network provider of medical services. This documentation must clearly demonstrate that the health professional is trained and qualified to treat patients in a given medical specialty and location. Like it sounds, this process can become potentially very time consuming for the average health professional. For example, every insurance provider has their own set of rules and procedures for becoming qualified in their network. At ABCS RCM, we have actually created guides for our clients in order to lead them through each insurance provider’s credentialing procedures.

Once a medical practitioner is fully credentialed with an insurance provider, he or she will need to monitor the in-network status. This monitoring is due to the fact that it is possible for credentialing to expire. When this occurs, health professionals will actually fall out of network, which reduces their overall rate of reimbursement.

For all of these reasons, if healthcare practitioners wish to make their back office more efficient and optimize their overall medical practice; they should seriously consider outsourcing the essential task of obtaining and maintaining insurance credentialing. This is an essential service that Advanced Billing & Consulting Services currently provides to their existing customers, who often find it invaluable.

Questions about medical credentialing? CONTACT US. ABCS also offers medical billing, website development and workforce management tools for Medicaid waiver providers.

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Obtaining Medical Credentialing, Insurance Providers