Credentialing in Medical Billing Systems
Credentialing in medical billing is crucial for ensuring patient safety and maintaining the quality of care provided by healthcare providers. This process involves verifying providers’ qualifications, competence, and eligibility, playing a vital role in effective revenue cycle management. In 2021, the Credential Management Solutions Market had a valuation of USD 833.45 Million. Projections indicate that it is expected to reach USD 2526.34 Million by 2030, experiencing a compound annual growth rate (CAGR) of 17.7% from 2022 to 2030. The rising cyber threat risk has spurred demand for skilled experts, credential management solutions, and IT security compliance software in businesses and organizations. (Credential Management Solutions Market Size, Share, Trends & Forecast, 2023) Figure 1. Global Credentialing Management Solutions Market https://www.verifiedmarketresearch.com/product/global-credential-management-solutions-market-size-and-forecast-to-2025/ Medical Billing Systems in Credentialing Medical billing systems are critical components of healthcare operations. They are used to submit and follow up on claims with health insurance companies to receive payment for services rendered by a healthcare provider. The role of medical billing systems in credentialing is quite significant. 1. Provider Information: Medical billing systems hold essential information about providers, including their credentials. This information is necessary for filing claims and verifying a provider’s ability to provide certain services. 2. Claims Processing: One of the key steps in processing medical claims involves verifying the provider’s credentials. If a provider is not properly credentialed with a particular payer, claims for services rendered can be denied, resulting in lost revenue. 3. Regulatory Compliance: Medical billing systems help maintain compliance with healthcare regulations, including credentialing-related ones. By ensuring providers are credentialed properly, the systems help prevent fraudulent claims and avoid potential legal issues. Integrating credentialing into medical billing systems can streamline workflows, improve accuracy, and increase efficiency. The integration can occur in various ways: 1. Data Sharing: Medical billing systems can be configured to share data with credentialing systems, allowing for real-time updates of provider information. 2. Automated Verifications: With the integration, systems can automatically verify a provider’s credentials during claim processing, flagging any issues for immediate attention. 3. Credentialing Updates: Updates to a provider’s credentials can be automatically reflected in the billing system, reducing the chance of claim denials due to outdated credential information. 4. Scheduling and Alerts: Medical billing systems can help manage credentialing timelines, offering reminders when it’s time for providers to renew their credentials, thus maintaining their eligibility with payers. Key Facts about Credentialing Applications Credentialing applications in the US healthcare system involve a significant volume of submissions. However, the success rate varies, with some applications failing to meet the requirements. The timeline for the credentialing process typically spans around 90-120 days, including the verification and contracting phases; per provider, there are 18 payers. For every 5 payer applications, 25 working hours of the hospital staff and physicians are consumed. Also, approximately 85% of the applications still need to be completed. (Shah, 2023) Figure 2. Basic Credentialing Facts Challenges in the Credentialing Process Incomplete or Inaccurate Documentation Incomplete or inaccurate documentation is a common challenge in the credentialing process. Thoroughly reviewing the application materials and seeking assistance, if needed, can help mitigate this challenge. Maintain clear records of all documentation submitted and maintain copies for reference and future updates. Insufficient Qualifications Meeting specific qualifications, such as experience, licenses, certifications, or exam scores, is crucial for successful credentialing. Regularly reviewing and updating qualifications, participating in continuing education, and seeking professional development opportunities help providers stay current and fulfill credentialing requirements. Lack of Adherence to Credentialing Standards Adhering to credentialing standards is essential for a smooth credentialing process. Familiarize themselves with the specific standards and ensure they comply with professional conduct, ethical behavior, and patient safety requirements. Regularly reviewing the credentialing standards and seeking ongoing education on changes or updates to these standards promote ongoing compliance and avoid potential challenges. Inadequate Professional References Successful credentialing requires credible professional references highlighting the provider’s skills, knowledge, and abilities. Establish professional relationships and seek references from respected individuals who can vouch for their qualifications and competence. Engage in professional networks to facilitate the collection of robust references. Disciplinary Actions or Malpractice History Providers with a history of disciplinary actions or malpractice may face challenges during credentialing. Credentialing organizations are concerned about the provider’s competence and safety. Prepare to address any disciplinary or malpractice history concerns and provide explanations or evidence of corrective actions. Seeking legal counsel or assistance from credentialing experts can help providers navigate these challenges effectively. (Shah, 2023b) Common Documents and Information Required for Credentialing Applications Typically, credentialing applications include: 1. Educational Background and Training Documentation: Healthcare providers must submit comprehensive documentation that validates their educational background and training. This includes transcripts, diplomas, degrees, and records of specialized training, fellowships, and continuing education courses. Accuracy in these documents is crucial as they reflect the provider’s expertise in their specific field of practice. 2. Licensure and Certification Details: Credentialing applications typically seek information about the provider’s current and past licensure status. This encompasses their medical license, board certifications, and any history of disciplinary actions or license restrictions. 3. Malpractice History and Insurance Coverage: Disclosure of malpractice history, including any claims, settlements, or judgments, is standard procedure in credentialing applications. This information helps assess the provider’s risk profile and ability to deliver safe, high-quality care. Providers must also furnish proof of malpractice insurance coverage or alternative means of financial responsibility. 4. Professional References and Recommendations: Credentialing applications often require professional references from colleagues, supervisors, or others familiar with the provider’s clinical practice. These references offer insights into the provider’s professional conduct, clinical skills, and teamwork abilities. Recommendations from respected professionals carry significant weight in the credentialing process and positively impact the provider’s application. 5. Practitioner Data Bank and National Provider Identifier (NPI) Registration: Providers are obliged to disclose any adverse actions or reportable events as required by the National Practitioner Data Bank (NPDB). This includes malpractice settlements, disciplinary actions, or exclusions from federal healthcare programs. Additionally, providers must obtain a National Provider Identifier (NPI) and include it in their credentialing application. The NPI standardizes
The Network Effect
People handle adversity differently; some break down sooner than others. When a team focused on a common goal faces adverse conditions, dissent among some team members precludes them from reaching a shared goal. Under extreme conditions, a mutiny isn’t just mission-critical—it can leave everybody dead. The famous explorer Ernest Shackleton, best remembered for his Antarctic expedition of 1914–1916 in the ship Endurance, managed such risks by assigning the whiny, complaining crew members to sleep in his own tent and share the chores with him. Clustering the “complainers” with him minimized their negative influence on others, and this helped his team survive and accomplish their goals. Medicare Vs. Private Payers It’s essential to acknowledge the contrasting dynamics between Medicare and private payers. Medicare, as a government-backed program, follows distinct regulations and reimbursement structures, while private payers operate in a competitive market with more flexible terms. The negotiation strategies and considerations may differ significantly when dealing with these two payer types. Payment negotiations Actively negotiating with payers is crucial for independent medical practices. However, many providers lack experience or haven’t been successful in past negotiations due to inadequate preparation. To ensure a fruitful negotiation, it’s vital to: Know Your Data: Understand your practice-specific data, including patient volume, charges, reimbursement history, and more. Know the Terms of Each Contract: Familiarize yourself with your current payer-specific contract terms, especially the reimbursement schedule and the claims filing data. (Babcock, 2021) According to a KFF analysis, as seen in the image below, private insurers often pay nearly double the Medicare rates for hospital services. Specifically, for outpatient hospital services, private insurance rates were found to be significantly higher than Medicare rates, averaging 264% of the latter. This difference underscores the varying dynamics and market powers between Medicare and private insurers. Policymakers and analysts continue to debate the necessity of high payments from private payers to compensate for the lower Medicare payments. (How Much More Than Medicare Do Private Insurers Pay? A Review of the Literature | KFF, 2020) Classification of Payment Models Payment models dictate how healthcare providers, including physicians and hospitals, are remunerated for their services. Each model inherently carries incentives and disincentives that can influence the balance between cost reduction and improving care quality. These two objectives often stand at odds. This report delves into the implications of Alternative Payment Models (APMs) in either mitigating or intensifying health disparities. However, before exploring these implications, it’s essential to understand the incentives and disincentives embedded within the prevailing payment models. These incentives play a pivotal role in fostering cost-efficient, high-quality care. The primary distinction among these payment methods lies in the unit of payment. This determines how financial risk is distributed between the payer and the provider. The nature of this risk can significantly influence the behavior of healthcare providers and the overall efficiency and effectiveness of the healthcare system (Quinn, 2015). Factors affecting payment negotiations According to AMA, it’s not just about the rates but also about the terms and conditions that can impact payment. For instance, some contracts might have clauses that allow payers to change rates without notice, or they might have stringent requirements for prior authorizations. Providers should be wary of “most favored nation” clauses, which can restrict them from offering better rates to other payers. It’s also crucial to be aware of the dispute resolution process outlined in the contract, should any disagreements arise. By being well-prepared and understanding the intricacies of payer contracts, providers can position themselves for more favorable negotiations and better financial outcomes. (American Medical Association & American Medical Association, 2022) Payer-provider conflict In the payer-provider conflict, the providers who accept lower reimbursement and who don’t challenge underpayments or delayed payments make it easier for the payers to maintain their market control (oligopsony). Recent research supports this notion, indicating that payers with larger market shares have more negotiating power in contract negotiations (HealthPayer Intelligence). ClinicMind’s network helps providers maintain their payment schedules and motivation by establishing a shared discipline for clients and billers alike in terms of both thought and action. Payers with Larger Market Share and Their Negotiating Power Payers that have a dominant presence in the local market have a distinct advantage when it comes to negotiating lower prices for physician office visits. A study conducted by researchers from Harvard Medical School found that health insurance companies with a market share of 15% or more negotiated visit prices that were 21% lower than those set by payers with a market share of 5% or less. For instance, payers with less than 5% of the market negotiated prices of $88 per office visit. In contrast, those with 5 to 15% of the market share settled for a price of $72, and those with more than 15% of the market share negotiated even lower at $70 per visit. The graph below shows this analysis. From Policy Changes to Physician Consolidation In 2010, President Barack Obama signed the Affordable Care Act (ACA) into law, a move that expanded Medicare’s reach by adding millions to its coverage. This expansion meant that more physicians had to accept Medicare rates, which have been systematically reduced over time. The ACA not only aimed to extend healthcare access to uninsured Americans but also set in motion a wave of consolidation in healthcare services. As Medicare adjusted its rates, private insurance companies followed suit. While they still paid above Medicare rates, they too began to reduce their payouts. This trend forced physicians to grapple with a challenging reality: working more hours for less pay. The Power of the Network Effect In response to these financial pressures, physicians began to see the value in consolidating their practices. By joining larger organizations, they could harness the network effect, gaining more significant negotiating leverage with insurance companies. This consolidation is not just about survival; it’s about strength in numbers. Large groups, especially those with revenues exceeding $1 million annually, have more room to negotiate than smaller entities. The Rise of Management Service Organizations (MSO) Amidst these challenges,
Are You Someone’s Hero?
In the last chapter we talked about hunger and the drive that must exist between all members of a patient community, including the patients themselves, but what about the patient’s need for a mentor? Remember in previous chapters we talked about how Joseph and Bonnie’s dispositions not only affected their ability to treat effectively but also resulted in lost patients? Patients, because they are people, respond and react to the emotions they receive. We don’t always react in the expected way, but that has more to do with the person interpreting than the person reacting. So how do we set ourselves up so that when we aren’t having the best day ever and performing at our peak state, our patients still receive the best care possible? The answer is heroism. And no, I’m not talking about superhero heroism like we see in the movies today. I’m talking about the heroism of someone behaving in a consistent and positive way that inspires others. When people see someone working harder than everyone else (and I don’t mean slightly harder, I mean orders of magnitude harder), they naturally want to help that person. Following success is a tremendous motivator for many because it means that they don’t have to expect 100% effort from themselves to achieve a goal. In other words, the responsibility isn’t 100% on them, and so they feel compelled to work as hard as possible, if not harder. We all know the power of heroes in fiction and how they inspire their comrades and even enemies, in many cases, to follow the path of good and righteousness. Take the most famous superhero of them all. Superman. As we prepare for the dawn of the Superman movies in cinema, these films raise powerful questions about what is meant by a leader. Many would say that Superman is an example of a great hero, but I would disagree. Superman is a great character and, in fiction, does amazing things for many. However, because his power is so great and far removed from our own, we don’t feel like what he does is ever enough (hence people never truly appreciate Superman except when their lives are on the line). As practice owners and clinicians, we’re often seen this way. We hold in our minds and hands, the ability to create massive change in a patient’s life, change that that patient would otherwise be unable to experience. This truly defines us as Superheroes, but it also presents a major problem. It means we are too far removed from our patients resulting in this kind of detached relegation. We feel compelled as patients to receive care and do so reluctantly, hoping we never need to return (think about it, how many patients truly want to be thinking about their illness?). Now take the example of the practice owner and how we react when we feel like superheroes. Sure, at the beginning, it’s an incredible ego booster, it makes us feel like we are kings and invincible. But then what? The feeling goes away, and we’re left with a patient roster that, quite frankly, is embarrassing by superhero standards. Naturally, this gives way to the feeling of inadequacy and negativity we discussed earlier. So what do we need to do? Simple (but not easy), we need to get closer to our patients. In other words, we need to close as much of the rift between a patient and their physician as possible. Since this is a natural phenomenon with man-made side effects, it is especially difficult to resolve. It means that we, as practice owners, have to first overcome our confidence needs to see ourselves as our patients see each other, powerful and capable. Above is a diagram that describes what I’m talking about. Nature develops these build-in separations as we grow in expertise and capability, but it also creates a lack of empathy and connection with our patients. The real question is, who is responsible for bridging this gap? Heroism lies in effective communication with patients and addressing their concerns holistically. As a practitioner, you should be able to listen to, understand, and share in people’s feelings, beliefs and experiences in order to take care of their real needs and offer individualized care rather than just focusing on the science of the illness. This is part of the spectrum of empathetic communication (Moudatsou et al, 2020). Several strategies can be used to effectively communicate with patients. These include active listening, using plain language while avoiding technical jargon, using relatable examples and illustrations, using appropriate language, keeping the interaction confidential and letting patients explain concepts in their own words to demonstrate understanding. (Tulane University School of Public Health and Tropical Medicine. Strategies for Effective Communication in Health Care. Sept 2021; Float Care 2023 ) Here’s a great personal example. In graduate school, I was a teacher’s assistant (professor lackeys or TAs as we were widely known) teaching the recitation for a course on statistics for Psychology undergraduate majors. These were first-year students who, for the most part, had no idea what they were doing, but also knew exactly what they were doing. As with most young people, there was a split, and although they needed guidance, they weren’t ready to admit it yet. This was clear in the first month as I clearly entered the room as an authority figure. I was confident in my knowledge of the material and ability to convey it in a manner that would instruct students (sounds engaging, doesn’t it?). Obviously, you can imagine what happened next: I inspired exactly zero students to actually be interested in the material and as a result, many did not pass the first exam. There was an uproar from the professor and from the students, apparently thinking that the recitations were the source of the problem. The professor sat me down for an hour over coffee and tea (I was the difficult one who didn’t and still doesn’t drink coffee), explaining the difference between
Are You Hungry?
Great, now Reuven wants to know if I’m hungry. Don’t worry, we’re not talking about hunger pains or anything like that. I’m talking about drive, the hunger to stop at nothing to succeed. But I’m also not talking about it in the most general sense. In other words, we’re not talking about all those Youtube videos dealing with motivation, drive, and hunger. I’m talking about the hunger unique to healthcare that is required to create a thriving practice. I’m talking about community hunger. When you want to put together a thriving patient community, regardless of specialty, of course, it’s critical that both you, your staff, and your patients feel a certain hunger. Gone are the days of thriving practices where patients simply receive care. Today, a thriving practice depends on the teamwork built between a patient and the staff in the office. However, anytime you have a team, you need teamwork based on a voracious hunger. A driving force that unites the team and propels them forward. Clearing objectives, roles, and expectations; providing training and support; promoting diversity and representation; providing incentives and feedback; and securing institutional support and sponsorship are all examples of effective patient engagement tactics, according to a systematic review on the topic published in Bombard et al. (2018). One of the biggest misconceptions about hunger and drive is that you must be an extrovert or high-energy person to derive strength from hunger truly. In fact, I’ve quite often experienced the opposite. In Joseph and Bonnie’s case, these two had opposing personalities, but Bonnie, who was more of an introvert than Joseph’s incredible extroversion, was clearly overcome by a stronger hunger. She was more consistent in her behavior and suffered from less burnout than Joseph. She was also more adaptable. She was able to empathize with both high-energy patients and low-energy ones. Experience really is the best teacher, and more often, it’s easier to understand high-energy people from a low-energy perspective than to understand low-energy people from a high-energy perspective. According to research, personality factors have been linked to job satisfaction and burnout among healthcare professionals. For instance, higher neuroticism levels have been associated with lower job satisfaction, increased emotional exhaustion, and depersonalization. Contrarily, agreeability and scrupulosity are positively connected with job satisfaction and adversely associated with depersonalization (Kang & Malvaso, 2023). These findings imply that managing burnout and enhancing worker well-being in healthcare settings can be facilitated by understanding various personality types. I’ll give you a personal example. I am a high-energy person who loves to be loud, talk fast, and get from A to B with as little in between as possible. I was always the quintessential type A personality who never enjoyed the journey because he was too caught up in achieving the destination. In school, that can often do well for you, as I always achieved top scores on exams and papers. However, my personal relationships suffered greatly. For example, I could never maintain quality friendships (although I had many friends), and forget about romantic relationships where you truly need to be present to be successful. Imagine being so caught up in the result of effort and bringing that to a romantic situation. Strong leadership is crucial in community-based healthcare practices. Effective community involvement projects have been shown to involve communities in planning, designing, implementing, and evaluating primary health care services. Community leaders are essential in promoting teamwork and driving the group toward shared objectives (Erku et al., 2023). Ultimately, I had to recognize the drawbacks of my personality and the opportunities that presented. In other words, what were the challenges I had to overcome, and how would those help me to become a better and more contributing individual? At the same time, I struggled because some of my friends had great connections, and I often felt that they were lazy because they spoke slower, didn’t engage at a super high level of energy, and often stayed home instead of constantly going out. It’s important to consider the varied personality types’ needs for recharge time (Grailey et al., 2023). Now we understand the difference in recharge time required for different personality types. For example, if you are more introverted, you can definitely be the life of the party, but afterward, you’ll need some time to recharge the batteries. There’s nothing wrong with this; in retrospect, I think this is more beneficial than constantly being out. The literature also emphasizes the importance of reflection and self-awareness in identifying one’s fundamental limitations and comprehending the advantages associated with various personality characteristics. Extroverts may thrive in social situations and get their energy from continual engagement, but introverts have a special ability to use deep thought and reflection to advance both personally and professionally. This implies that accepting and comprehending one’s innate characteristics might result in personal growth and achievement in a variety of areas of life (Grailey et al., 2023). It challenges us to search for that hunger within instead of constantly being hungry for what’s outside of us. In my personal struggle to expand beyond my core limitations, I recognized the incredible power of introverted people and how I could leverage that to grow personally and professionally. However, one of the biggest mistakes people make is thinking they can grow this way independently. In other words, they think there is a way for them to simply absorb this information without help. Nothing could be further from the truth. Studies have underlined the value of mentoring for improving patient outcomes, career growth, and skills in healthcare settings (Nandwani, 2023). The analogy of hunger shows how, similar to the body’s requirement for nutrition from outside sources, people may need coaching to comprehend and successfully realize their inner desires. Without the right direction, they could make detrimental decisions repeatedly, just like when they consume “junk” without understanding their genuine needs. Mentorship serves as a compass, assisting people in discovering their true desires and fostering both personal and professional development. Think about your body, your purest form of