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Are You Getting the Most Out of Your Credentialing?

Are You Getting the Most Out of Your Credentialing?

Are You Getting the Most Out of Your Credentialing?

Enrollment status can greatly affect the dollar amount payers reimburse, and some specialists are opting to go out of network. We weigh the pros and cons of this trend to explain why it may make sense for select providers.

Did you know that reimbursement is directly tied to credentialing? It’s all in the details, and enrollment status can greatly affect the amount payers reimburse. When enrolling as an in-network provider, payers and providers decide on an agreed-upon rate. However, a physician can decide to forgo a traditional contract with a payer and instead choose to be labeled as “out of network”. Of course, they will still be listed as a provider, albeit without the stated reimbursement rates and payment security that comes with having a contract in place.

If you are wondering why this option is appealing to some physicians, just look at common treatments the average healthcare consumer may be familiar with. Every year, most adults and children visit their local eye specialist for an annual exam. An optometrist performing a routine eye exam will most likely receive optimal reimbursement. This service is covered by insurance in the majority of cases and the reimbursement will be within a standard range. However, if this same patient is then referred to an ophthalmologist for advanced cataract surgery, for example, the odds of insurance covering this procedure are less likely. From the standpoint of the ophthalmologist, his credentialing specifics may not matter too much, since he will be paid regardless and the patient is most likely assuming that they will have a large out-of-pocket cost. When all is said and done, the ophthalmologist is set up to take home more than if he was listed as an in-network option. Looking at it through the eyes of the surgeon, it would not make sense financially to be credentialing with payers the traditional way.

The benefit of being in-network boils down to the contracts that determine what providers will be paid. When a provider works with a payer, an agreed-upon rate is determined. If paperwork is filled out correctly and claims are submitted on time, there will not be too many surprises when the time comes to be reimbursed. A provider will know what to expect from a particular service. This process works best for providers that like the security of having a contract in place. However, these contacts with insurance companies often result in providers being paid less than fair market value. The truth of the matter is that fair market value may often be more than payers are willing to pay.

It’s not uncommon for family doctors, or eye care professionals that deliver routine exams like the example mentioned above, to work in-network because the margins are small.  For highly specialized services, often considered elective and not covered by insurance, the potential for large reimbursement grows significantly. For instance, let’s say a plastic surgeon performs surgery in their own surgical suite. The procedure may cost $14,000. Through payer reimbursement as an in-network provider, the surgeon receives $4,000. However, if the surgeon is considered out-of-network, they have the ability to negotiate rates, meaning much more could potentially be earned. From the patient’s standpoint, it’s not uncommon for a patient to shop around and expect to use an out-of-network provider anyway for these types of highly specialized services.

When it comes to gaining credentials, an out-of-network provider will not have to go the traditional credentialing route. This question arises: Is it smarter for medical professionals to perform their services as in-network or out-of-network providers? The truth is, a lot of doctors do not actually realize they have the ability to negotiate. It all comes down to how they want to pay, and the power lies with the provider.

Credentialing is complicated, and it helps to have the right partner in place to navigate the path to credentials. TriZetto Provider Solutions (TPS) has experienced credentialing experts in place that can help with every aspect of the process. Visit our TPS partner page to learn more and request a demo.


ABOUT EZCLAIM:
As a medical billing expert, EZClaim can help the medical practice improve its revenues since it is a medical billing and scheduling software company. EZClaim provides a best-in-class product, with correspondingly exceptional service and support. Combined, EZClaim helps improve medical billing revenues. To learn more, visit EZClaim’s website, email them, or call them today at 877.650.0904.

EZClaim Support

EZClaim Support

From year to year, EZClaim’s Support Team has one thing in mind—to improve continuously—and 2021 has been no different. EZClaim’s Support Team has implemented a new Service Desk—powered by Hubspot—which includes enhanced automation, automated surveys, a comprehensive Knowledge Base, and more.  In 2022, we will launch an interactive online chat and more.

Hubspot has allowed EZClaim to go to another level in supporting customers, and with our customer’s help, we can get even better!  EZClaim launched an updated ticket website (www.ezclaim.com/ticket) that provides categories to choose from when creating a ticket.  These categories are linked to a group of team members that are experts in those categories.  That means, if you select the category ‘Importing from EMR,’ your question will go directly to the importing experts.  For more tips to help get your answers quickly, please view this support tickets tip page!

EZClaim can also use your help by providing feedback from your support ticket experiences and how easy EZClaim’s Support Team makes it to get your issues resolved.  After a ticket, you submit is closed, you will receive a survey in your email.  The survey asks you to rate the experience on a scale from 1-7 and provide any comments that you may have from your experience.  These survey responses help tremendously by giving us feedback for things we’re doing right and things we need to improve.  EZClaim’s mission is to improve continuously, and the best way to improve is to get feedback!

EZClaim is excited to continue to improve the customer experience and we look forward to implementing new and better things in 2022!  We would like to thank each and every one of you for your continued support and patronage throughout each and every year.

We hope everyone is safe and healthy going into the holiday season!

All the best,

EZClaim Support


ABOUT EZCLAIM:
As a medical billing expert, EZClaim can help the medical practice improve its revenues since it is a medical billing and scheduling software company. EZClaim provides a best-in-class product, with correspondingly exceptional service and support. Combined, EZClaim helps improve medical billing revenues. To learn more, visit EZClaim’s website, email them, or call them today at 877.650.0904.