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.

Full Practice Authority for NPs Continues to Grow

Full Practice Authority for NPs Continues to Grow

With two more states recently joining the list of locations that allow Full Practice Authority, many nurse practitioners are exploring the option of operating independently. As the need for qualified healthcare professionals continues to grow and the ability for NPs to practice independently continues to increase, quickly gaining credentials and navigating compliance challenges becomes more and more important.

Recently, Massachusetts and Delaware became the latest states to enact Full Practice Authority (FPA) for nurse practitioners (NPs), bringing the total number of states to 24. With this new inclusion, nearly half of U.S. states now allow nurse practitioners to operate on their own. Essentially, this means that registered nurses can practice independently from physicians, allowing for more autonomy in their careers and the care they provide.

So why this is significant? This means that registered nurses can practice independently from physicians, allowing for more autonomy in their careers and the care they provide. Nurses are no longer “tied” to physicians, so to speak.

These new laws cannot come at a better time. We know that the amount of practicing medical doctors has dwindled in recent years, due to the pandemic and many providers leaving the field. This has led to a short supply of physicians in the U.S., which has only 2.6 practicing physicians per 1,000 people, compared to 4.3 in Sweden and 3.2 in France. This decrease is driving unprecedented demand for nurse practitioners (NPs), with an expected increase of 52% through 2029.

Traditionally, state practice and licensure laws required NPs to have a career-long collaborating or supervising physician to provide patient care. However, with more and more states allowing Full Practice Authority, now nearly half of U.S. states now allow nurse practitioners to operate on their own. But in order for NPs to move forward with independent practice, credentialing is essential. How can nurse practitioners looking to establish their own practices quickly gain credentials and painlessly navigate the challenges of compliance?

Operating independently means nurses need to establish credentials as a standalone provider to be eligible for in-network status to receive physician-level reimbursements. These tasks, and complying with the Council for Affordable Quality Healthcare’s (CAQH) requirements, can be taxing and time-consuming, even for the most seasoned professional. Creating a new CAQH application is highly manual, and the required quarterly updates for re-attestation can be onerous. Extensive credentials including education, residency, internships, and peer references are also required, which require time to gather information and resources. It’s not an exaggeration to say that many hours must be spent uploading copies of licensing information, board certifications, DEA registration, and insurance certificates.

NPs looking to leave their current situation may need help navigating credentialing challenges. Partnering with a third-party provider to help manage credentialing lightens the load and allows nurses to focus on patient care. TriZetto Provider Solutions (TPS) offers an end-to-end credentialing service that ensures continuous payer follow-up and insight into enrollment status.

Discover the most painless way to gain credentials. Visit our TPS partner page to get started.


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.

 

Medicare Revalidation is Critical to Maintaining Eligibility

Medicare Revalidation is Critical to Maintaining Eligibility

Medicare is the largest payer for most practitioners, so it’s important that providers maintain current credentials. Medicare requires providers to revalidate every five years to verify credentials and ensure they meet Medicare qualifications. Providers must confirm or update information including the legal entity name, physical address, phone, fax, national provider identifiers, employer identification number, and board certifications and licenses if applicable.

While typically a straightforward process, if not completed correctly and on time, providers will be terminated from the program and required to reapply. Until a new application is processed and approved, which can take anywhere from 90-120 days, reimbursements will stop, disrupting the revenue cycle.

Occasionally, providers may receive off-cycle revalidation requests. These are typically triggered when anomalies are identified such as billing rates that are significantly higher than other providers in the same geography, billing for services not rendered, or billing patients for services that Medicare doesn’t allow.

To comply with Medicare revalidation requirements, providers need to know their revalidation schedule and make sure applications and supporting documentation are submitted through Medicare’s PECOS online application portal. Revalidation dates cannot be extended, so it’s important they’re submitted on time. Using a third party to navigate the nuances of Medicare revalidation and PECOS removes the burden from provider staff and ensures accurate and timely filing.

TriZetto Provider Solutions (TPS) offers an end-to-end credentialing service that includes continuous payer follow-up and insight into enrollment status. Our dedicated team takes provider data, verifies it for accuracy, and submits credentials for revalidation through PECOS. All Medicare-participating providers are subject to revalidation, and mistakes made before or during the process can result in loss of eligibility and other penalties.

Having nearly four decades of experience working with payers and providers, the TPS credentialing experts understand the importance of maintaining current credentials. Contact us to learn more about our Medicare revalidation services.


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.