The process of getting a physician or a provider affiliated with payers, is a critical step in the revenue cycle. This process enables patients to utilize their insurance cards to pay for medical services consumed and enables the provider to get reimbursed for the medical services provided. In order to ensure that your facility does not suffer from this, it is important that credentials get and enrolment of your providers is managed properly and kept up to date. Therefore, it is important for healthcare providers to get enrolled and credentialed with maximum payers so that patients can use their insurance plans in your practice. Failure to do so can and will have a negative impact on your revenue cycle. However, the process of getting a provider credentialed with a payer involves a lot of manual work in terms of completing the application forms, providing clarifications to questions from payers, and following up with them to close the credentialing request. Add to this, the regulatory requirements under which your facility can be at risk of compliance violations. To ensure that your provider credentialing and enrolment processes are managed properly, it is important to understand the difference between the two.

Provider Credentialing

The process involves the following steps:

  • Completing the required documentation and identifying exceptions.
  • Verify practitioner/ facility information from physicians.
  • Obtain missing documents and updating the payer’s database.
  • Follow-up on submitted credentialing requests.
  • Capture data, label, and link images to specific providers/ facilities in the payer’s database.
  • Update provider information as per policies and procedures, and the CAHQ profile.

Provider Enrollment

Our Provider Enrollment services enable practices to get enrolled for the services they provide by ensuring that payers have the data they need to process claims for the services you provide. We constantly monitor the payers to ensure applications are received and processed on time. We work diligently to identify and resolve potential administrative issues before they impact your provider reimbursements.
The process involves the following steps:

  • Contact payers to determine if they have the correct provider information on file before we submit claims
  • Validate and update the provider’s pay-to address or the billing address
  • Our team can enroll providers for four types of electronic transactions – Electronic Data Interchange (EDI), Electronic Remittance Advice (ERA), Electronic Fund Transfer (EFT), and CSI.
  • A group of highly skilled team members trained to perform research and analysis on the possible processor functionality gaps.

Our value proposition

  • Keep your data up-to-date with the payer
  • Process faster payments from insurance and get more patient referrals
  • Mitigate revenue leakage
  • Avoid piles of paperwork and filling-up application forms
  • Reduce denials and identify provider trends
  • Build relationships with different payers.
  • Provide real-time status of credentialing and enrollment transactions.

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