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Importance of Contracting and Credentialing for Medical & Healthcare Practices

Contracting and credentialing are the foundation of any medical practice. If credentialing is inaccurate for your provider group, or your contracts are outdated with poor fee schedules, these issues cause denied claims and loss of revenue. One of the best things you can do to protect your practice is to ensure that your credentialing is completely current for all providers in your practice and that payer contracts ensure reasonable rates for all your services. Larsen Billing can help you ensure you are correctly set up with every payer you bill.

What is credentialing in healthcare?

Credentialing in medical billing is the process of sending in required documentation to payers before providers can be enrolled with insurance plans. Payers must know that providers have the proper education, training, and licenses to care for patients. This critical safety check ensures patients receive care from healthcare professionals who have undergone stringent scrutiny. Medical credentialing specialists gather all the necessary information that payers require and send all this data to the payers on your behalf. If a provider has been credentialed previously with another group, a payer can be prompted to gather that data and move it to a new group as needed. Credentialing for new providers can take a couple of months, depending on the payer.

What is contracting in healthcare?

Contracting means that the payer has agreed to send the provider or group a contract to sign that binds both parties to an agreement: the provider group will provide X services for X rates, according to the fee schedule; providers must accept the contracted rate as payment in full.

Contracting is the lengthier part of the process; it can take six months to a year to get a contract in place, depending on the payer. There is no guarantee a payer will offer a new contract, even if the provider meets all credentialing requirements. Payers sometimes respond to contract requests by saying the network is closed, meaning they are not offering new contracts to providers within a particular specialty or in that geographic location. However, if the patient demographics or the availability of providers in the area change, there may be future opportunities for the provider to secure a contract.

The insurance company will pay for those services at the in-network level if a contract is obtained. When a provider is contracted with an insurance plan, that provider is called “participating” or “in-network.” Conversely, when no contract exists, the provider is considered “non-participating” or “out-of-network.” If a patient has out-of-network benefits, providers can bill out-of-network and still be paid; typically, deductibles and co-insurance percentages are higher with out-of-network benefits, making the patient’s out-of-pocket costs higher.

Issues That Practices Are Having

At Larsen Billing, our contracting and credentialing team has seen practices come to us with issues in these areas that we find out is drastically impacting the cash flow for the practice.

  • Some practices have contracts that haven’t been renegotiated in over ten years; very low payment rates mean the practice isn’t receiving nearly the revenue it needs to operate well.
  • Some practices only have a couple of providers credentialed or enrolled with payers, while many other providers never credentialed are seeing patients. This leads to the temptation to bill fraudulently by submitting claims under credentialed providers in a situation where billing “incident to” is inappropriate.
  • Some providers want to bill out-of-network to some payers, but they have no idea how to get their practice loaded as an out-of-network group with the insurance plan.

We have experts at Larsen Billing who spend all their time fixing these issues; our services ensure your credentialing, provider enrollment, and payer contracts are current for your entire practice.

Why Contracting and Credentialing Matters for Your Practice

Contracting and credentialing are the first steps toward generating revenue if providers intend to bill insurance companies for their services. However, if your contracting and provider enrollment processes aren’t solid from the beginning, all other aspects of your practice will crumble.

Your contracts directly affect your cash flow. Contracts must be negotiated and approved correctly before you render services. If your contracts aren’t nurtured, fostered, and regularly evaluated to ensure accuracy, you will see an increase in claims denials.

Though crucial and essential components of your practice, most providers often neglect to contract and credentialing. Understandably, a provider’s primary focus is caring for patients and serving the community. But you won’t be able to do your job effectively if your contracts with insurance companies and your credentialing are not correctly managed.

This might seem like a trivial aspect of your medical practice. However, it’s the building block upon which everything else stands, especially when successfully billing insurance and generating cash flow are necessary to operate a successful medical practice. Many practices report that the most significant factor contributing to claims denials and loss of revenue is not being current with their credentialing and contracting.

Keeping Up with Evolving Medical Legislation

Recent updates to medical legislation and credentialing requirements require providers to ensure their data and information is up-to-date and accurate. Contracting and credentialing are two components of practice transparency that you must consider before seeing your first patient. In addition, you cannot communicate to your patients that you are in-network with an insurance plan until after completing this work.

At Larsen Billing, we serve new and established providers who have neglected their contracting and credentialing. Sometimes, these requirements are overwhelming, time-consuming, and complex. Many practices don’t have the resources, medical credentialing process, or knowledge to handle them in-house.

The team at Larsen Billing provides these services so providers can continue doing the things necessary to you: providing optimal patient care. In addition, our team ensures your contracts, credentialing, and demographic information is updated, meets all payer requirements, and follows the most recent medical legislation.

The recent legislation called the No Surprises Act is an excellent example of something physicians and practices must be aware of. The purpose of the No Surprises Act is to prevent patients from receiving medical bills they aren’t expecting. The act applies to any provider serving uninsured patients, requiring that providers give accurate written estimates to patients before care is rendered. The guidelines are particular; it even requires that providers keep their payers apprised of their office hours. At Larsen Billing, we update our clients about legislative changes like the No Surprises Act and provide support to help you understand your responsibilities.

How To Get Out of a Bad Insurance Contract

Providers often feel stuck in a bad contract with an outdated fee schedule. However, once you obtain an insurance contract, you can receive the same reimbursement amounts for years unless you proactively renegotiate.

You don’t have to stay in terrible contracts. You can call your payers and attempt to renegotiate your contracts if you like. However, if you don’t have the time or capacity to manage contract negotiations, Larsen Billing can relieve you of this time-consuming task. The team at Larsen Billing advocates for you so you can receive appropriate compensation even with market changes and fluctuations. Contract evaluations and negotiations empower even the smallest medical practices to remain sustainable and provide care for their communities.

How To Maintain Long-Term Compliance

Maintaining compliance consumes valuable time and energy, but you cannot overestimate the importance of establishing and maintaining your credentialing and contracts. Securing your credentialing and completing initial contract negotiations is the first step, but it’s not the last.

Maintaining compliance is an ongoing process that must be closely monitored. It’s a small piece of your practice, but as discussed above, your practice’s success is built upon it.

How Larsen Helps Maintain Long-Term Compliance

Larsen Billing provides compliance expertise that preserves your resources while delivering contracting and credentialing assets that help your practice thrive with the following services:

  1. Securing initial payer contracts – Our team negotiates your contracts, ensuring you receive compensation for the services provided.
  2. Provider enrollment – We ensure providers are associated with your insurance contracts and maintain their credentialing.
  3. Monitoring and maintaining all contracts and credentialing – Credentialing processes are time-sensitive, with some lasting as little as one year. Larsen Billing employs specialized credentialing software, Modio Health, that ensures you never miss a credentialing or contracting deadline. You don’t have to rely on paper mail or email notices that get lost while running your practice. We plan for your future, staying on top of your renewals and deadlines so you don’t have to.
  4. Maintaining and updating practice demographics information – If you change offices, addresses, tax ID number, or even your phone number, our team ensures your insurance partners are aware of all information updates.

Contracting and Credentialing Made Simple with Larsen Billing

Larsen Billing has the resources and connections that allow us to handle your contracting and credentialing efficiently. Our team of experts ensures thorough completion and submission of your paperwork, maintaining your contracts and credentialing at present and for the long term.

Never worry about missing a deadline or misunderstanding the fine print of medical legislation. Instead, reach out today to learn how the medical credentialing and contracting specialists at Larsen Billing can simplify your credentialing and contracting, returning precious resources to you and your practice.