A Complete Guide for DME Providers about Credentialing & Re-Credentialing
What do you need to know about Credentialing and Re-Credentialing as a DMEProvider?
It takes a lot of time and patience, as well as perseverance mixed with some luck to start a DME business. Just like when you start a new business, there are a thousand things you have to do. The problem is that a Durable Medical Equipment business has unique requirements that must be met before it can open its doors.
As a provider of Durable Medical Equipment, you must ensure that your clients or patients can afford your services. The majority of small businesses accept payments through plastic, but most often when clients hand you plastic, it is their insurance card.
Credentialing and Re-Credentialing in DME business
It is important to update the credentialing of any new physician, nurse, or other healthcare practitioners when they join the team. The credentialing process ensures that medical providers possess the skills and qualifications required to perform their duties professionally.
A provider of DME needs to reapply to the insurance panels every time they change employers, even if they have been approved initially. As part of the re-credentialing process, all DME providers are inspected periodically to ensure that they are still qualified to practice and are willing to join the network.
In most cases, credentialing and re-credentialing are expensive and time-consuming processes that can diminish your resources’ efficiency. As a way to make the process more transparent, Baruch Business Solutions has developed a guide to be used by healthcare providers to review the seven key steps involved with obtaining credentials.
Credentialing and the value it brings
Let us begin by answering the question, “Why credentialing in the healthcare field is so important?”
All healthcare facilities are required to ensure that their DME providers have the necessary credentials to process insurance claims, otherwise known as healthcare credentialing. Credentialing is essential in ensuring that the necessary patient care can be accessible for all patients, regardless of their insurance status or willingness to pay for it themselves.
There are differences in the processes for physician credentialing and re-credentialing among healthcare providers. Credentialing is not just important for physicians; it is also important for:
- Providers of dental care and dentists
- Healthcare organizations and hospitals
- Counselors and psychologists
- A licensed massage therapist
Your credentialing department must abide by the guidelines set forth by the following federal agencies in order to continue to be eligible for Medicare and Medicaid:
- Accreditation of healthcare organizations by The Joint Commission
- The Centers for Medicare & Medicaid Services (CMS)
Each state has its own requirements for credentialing, apart from these federal regulations.
Understanding and following these requirements will help you reduce your business liability when an incorrect or malpractice claim is brought against you.
Credentialing is a time-consuming and tedious process, as discussed above.Make sure all your healthcare practitioners receive their credentials in a timely manner by following these steps:
1. Identification of the essential documents
As you begin the credentialing process, keep in mind that each insurer will require different forms and documentation. Each insurer that you intend to work with requires that you submit the completed applications. An oversight can delay the approval of a project by several weeks or months even if only one piece of information is missing.
A list of all insurance providers you intend to work with should be made. Make a list of all the required documents for each insurer.Examples include, but are not limited to:
- Social Security Number (SSN)
- Demographic associated data such as gender, languages spoken, etc.
- Evidence of licensure
- Address information and Education
- Claim history
- Insurance proof
- Specialties and much more.
Your records should include most of this information along with the practitioners’ resumes and applications. Make sure that the information is as current as possible.
2. Make insurers a priority
The application process requires multiple documents, so you might want to prioritize which dossiers you should submit first.
Make sure to complete your credentialing with your primary insurer if most of your medical billing goes to them.
Maintain an understanding of the regulations and compliance of each insurer. For providers with credentials updated in other states, some insurance companies allow a streamlined process.It results in faster approvals.
Those providers who already have credentialing in other states may be able to fill out an abbreviated application with some insurers.
Compile all the applications and necessary documentation according to your priority list.
3. Maintain accurate and up-to-date information
Make sure that all the information provided is current and accurate before you apply. Please review the following details before submitting:
- Background checks should be performed.
- Make sure education details, board certification, licensing, and goodwill is verified through healthcare organizations such as AMA, ECFMG, etc.
- The history of privileges, credentials, and insurance claims should be reviewed.
- Any sanctions in the Office of Inspector General (OIG) records should be listed.
A submission form containing any kind of error can be very concerning:
- Ensure that the former employers are able to provide accurate information on the months and dates of employment. Otherwise, the approval process may be delayed.
- It is also possible for incorrect phone numbers or referral contacts to hamper your application.
- Similarly, neglecting any past malpractice cases can result in disqualification from the credentialing process.
You must present all the documents to the management of your facility after they have been gathered and verified.It is up to them to determine what privileges the new healthcare provider will receive. This information is critical to the credentialing process, and it cannot be overlooked.
Methods such as manual verification and other
Does any alternative verification process work better than manually verifying all provider information?
It is common for healthcare facilities to re-credential and credential in the traditional manner by calling and emailing the appropriate references, such as medical schools, American Medical Associations, and other key associations for verification of the practitioner’s credentials.
This process can have a detrimental effect on the speed of the process, as it is time-consuming.
There are several other options, including:
Credentialing software : It is possible to automate some of the credentialing processes with software programs like the Ready Doc and Modio, which cross-reference the application and resume information with the AMA profiles and the OIG.
Outsourcing : Do you feel overwhelmed by the credentialing process?You can save a great deal of time and money if you outsource your credentialing to an offshore provider.
When you’re confident about the accuracy of the information, you can move forward.
4. Completion of the Council for Affordable Quality Healthcare (CAQH)
The Council for Affordable Quality Healthcare is an organization that many major healthcare insurers require their partner facilities to apply (while the insurer also checks their applications for credentialing).
The insurer will provide you with a CAQH number and also an application invitation once you apply.
Alternatively, you can complete the CAQH form on paper or online.
In case the CAQH completes the form on paper, you have to enter the data manually. It is approximately 50 pages long and is best completed by a computer (since the manual entry of data would be an inefficient process).
If information is incomplete or inaccurate, CAQH applications can be delayed significantly.
As soon as you submit the initial application, be prepared to re-attest. A re-attestation is required at least four times a year to ensure that the insurance eligibility remains consistent.
5. Wait for the completion of verification
You have to wait for the insurer to approve the application once you submit it to them. The process can take a long time.
For the most part, credentialing can be completed within 90 days, but experts recommend that you give yourself 150 days. If there are serious differences, credentialing may take even longer.
6. Make sure you follow up
The key to getting your application approved on time is to followup with your insurer consistently, particularly if you haven’t heard from them. You can do this by:
- Maintain a positive relationship with the top executives and other staff members at the insurance company in order to make certain the applications reach them on time.
- To maximize your chances of receiving a response, check over a call rather than email.
- Whenever additional information is required, compile and verify all the documents in a timely manner and submit them.
7. Getting re-certified
It won’t take long for the insurer’s panel to verify the credentialing of your provider. However, it does not mean they will remain credentialed forever.
Keeping your credentials up-to-date and maintaining them requires constant effort.
- It is important that insurers are notified if an employee’s information is incorrect. It could result in the revocation of your license if any erroneous information is discovered before the correction is submitted.
- Re-credentialing is required every three years for most providers.
Management of credentialing and re-credentialing can be made easier with credentialing software. Also, it should be able to notify you when an employee’s credentials need to be renewed.
At the expiration of every three years, specific insurers should also send a renewal notice. It is important to respond promptly so that your provider can continue his inpatient care without interruption.
Have you been frustrated to follow up with the insurers for a while? Baruch Business Solutions has the experts you need!
You may have to dedicate a great deal of time and energy to dealing with insurers.In addition to negotiating the payment contracts, constant attention is required to ensure that the process runs smoothly.
It’s easy to get help with BBS! Since we know how important it is to care for your patients, outsourcing credentialing and re-credentialing is an excellent way to free up your resources for other important tasks.
Our team is happy to assist you with the entire process at a great level of transparency. Call us right now at +1 (323)-843-0055 to speak with our experts!