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Credentialing Services Can Prevent Out-of-Network Charges

Credentialing Services Can Prevent Out-of-Network Charges

*This post was written by our partners at TriZetto Provider Solutions.

With the cost of care steadily increasing over the last decade, healthcare consumers are finding themselves with higher deductibles and out-of-pocket expenses. Most consumers know utilizing innetwork care is the most economical option, but sometimes that is beyond a patient’s control.

You may have heard of the Massachusetts man who received a $3,700 medical bill for the services of an out-of-network anesthesiologist at an in-network hospital. Surprise bills like this occur when patients are seen by providers outside their health plan’s contracted network. A 2016 KFF survey found that nearly 7 out of 10 patients with medical debt did not know a provider was out of network at the time of service. So how exactly does this happen?

Let’s say a patient goes to the hospital for a scheduled surgery. After researching the best specialists, he finds a surgeon in his preferred network. Prior to surgery, he is administered anesthesia. Unbeknownst to him, the anesthesiologist is out of network. To sum it up, the patient was administered a service at an in-network facility by an out-of-network specialist. This is often seen when emergency and ancillary services like anesthesiology, radiology and pathology are subcontracted by a hospital.

Another common occurrence happens when recommendations come into play. Perhaps a patient recently had ACL reconstruction surgery. While the surgeon might be in-network, maybe the recommended physical therapist is out-of-network. If the patient assumes the referring physician would recommend a therapist in network, a surprise bill could appear in the patient’s mailbox after the initial session.

When an out-of-network provider bills for care, the payer is obviously going to cover less of the cost than the patient expects. The remainder will then be the responsibility of the patient. Out-of-network practitioners, not bound by any contractual, in-network rate agreements, are legally allowed to bill patients for the remaining balance, much to the chagrin of patients who thought they were utilizing in-network providers. This practice is known as balance billing.

These circumstances are sometimes out of a patient’s control. Not only is the patient inconvenienced with a hefty bill, but added stress is put on the billing department and practice as a whole when out-of-network providers come into play.

A 2016 KFF survey found that nearly 7 out of 10 patients with medical debt did not know a provider was out of network at the time of service.

Imagine a small dermatology office wants to add specialty providers that will allow the office to offer expanded services like plastic surgery. The same scenario can apply to a mental health facility that utilizes both mental health practitioners and those associated with emergency care. The providers would most likely need to be re-credentialed and claims could be denied if credentials are not processed in time, not to mention the potentially unpaid balances from unhappy patients who receive bills from out-of-network in-house specialists. Another instance where this could easily become an issue is when employers are involved. Perhaps a new job causes a change in insurance, but the employee still visits their family practitioner, not aware that the doctor is now out-of-network.

Unfortunately, this happens more often than we think. So much so that state and federal governments are considering legislation to address the problem. So who is to blame and how can the issue be prevented? Is the onus on insurance companies to proactively help physicians gain credentials and become in-network, or is it on the physician to know what health plans are popular in their region and ensure they gain credentialing with all? One way to help mitigate the issues associated with balance billing is to stay on top of credentialing. If providers are in-network with as many health plans as possible, the likelihood of getting paid quickly and accurately increases. A lot of health plans will even retroactively backdate credentials if applications are submitted timely.

Hiring third party credentialing experts is a way to make sure all credentialing bases are covered. For companies experienced in handling the nuances of credentialing, who are well versed in the regulations and requirements needed by various payers and states, it is a less-stressful way of navigating the credentialing process.

Don't allow the complicated payer credentialing and enrollment process to be a burden on your practice!

Our credentialing partners at TriZetto Provider Solutions have experience working with various payers and providers of all backgrounds. Their team of experts will collect and submit information in a timely manner and perform all necessary follow-up tasks. Let TriZetto lighten your load so you can focus on patient care and growing your practice. For more information or to request a quote, visit the TriZetto partner page.

Questions about the Credentialing process? Fill out the form below:

Infographic: 13 Steps to Limit Credentialing Mistakes Before They Happen

*This post was written by our partners at TriZetto Provider Solutions.

We all like to think we’re experts: In car repair. Home improvements. Computers. Cooking. That’s why there are so many internet fail videos demonstrating the disastrous, often hilarious, outcomes of cooking catastrophes and home repairs gone awry.

With that idea in mind, here are the thirteen common steps in enrolling a new provider with a payer. Based on this list, credentialing might seem like something an accomplished DIYer could complete in a few weeks. If only it were that easy:

13 Steps to Limit Credentialing Mistakes Before They Happen Infographic

Questions about the Credentialing process? Fill out the form below:

Decoding the Hidden Costs of Credentialing

Decoding the Hidden Costs of Credentialing

*This post was written by our partners at TriZetto Provider Solutions.

It’s safe to say that healthcare practitioners are well aware of the importance of credentialing. Beyond the legalities required of practicing physicians, credentials are needed for a practice’s revenue cycle to function properly. If providers aren’t enrolled with payers, they can’t receive payment for submitted claims. It’s as simple as that.

New and existing providers are required to maintain credentials and it’s not an easy process, even for the most well-oiled office. In order to take on the most patients and collect optimal revenue, practices also need to accept a wide array of payers. In fact, there has been a 5 percent uptick in providers enrolled with 10-20 payers, according to VerityStream’s 2018 Provider Enrollment Survey. Gaining enrollment with these payers involves verifying qualifications in order to accept patients, submit claims and ensure a steady stream of cash. Administrators need to collect the educational history of providers, fill out forms and submit the applications. It sounds easy enough, right?

Think again. There are hours of administrative work needed and a high risk for human error, with any hiccup in the process likely causing delays. It’s been said that up to 85% of credentialing applications are incomplete, which could cause delayed billing, lost revenue or even audits.

When it comes to credentialing, time is money. A 2016 survey by Merritt Hawkins found that a non-credentialed doctor was losing approximately $6,600 a day. Multiply that by the total amount of physicians in a given practice, and the potential losses are staggering.

“Up to 85% of credentialing applications are incomplete, which could cause delayed billing, lost revenue or even audits.”

Credentialing is a necessary evil, so do you handle in house or outsource? That’s the million dollar question. Utilizing current staff resources sounds like the easy solution, but does your organization have a dedicated employee to focus on your credentialing needs? Probably not. Chances are, this employee is pulled in many directions and isn’t able to dedicate time solely to credentialing. And if you do plan to handle the process with current staff, are your employees well-versed in all payers and their processes? Factor in learning curves or potential staff turnover and the time associated with training new employees and the not-so obvious financial costs quickly add up.

So how does the average practice streamline the process and ensure that credentials are gained as painlessly as possible? The old adage “you get what you pay for” could easily apply to this scenario. Hiring an outside resource means you are essentially paying for expertise and efficiency, which will save time and money in the long run. Why wouldn’t you want to utilize expert resources with in-depth knowledge of payer and state nuances? However, before making a  decision, you need to know how much your practice could save by using a third party. Knowledge is power and having an accurate picture of your potential revenue is the first step to determining the best option for your organization.

Access the credentialing ROI calculator from TriZetto Provider Solutions, a Cognizant Company, to receive an estimate of potential revenue savings. Discover the hidden costs associated with the credentialing process and see just how much revenue your practice could gain in 2020. You’ll gain enrollments quickly and accurately, keep employee satisfaction levels high (since they won’t be burdened by the process) and ultimately, increase revenue.

Don’t allow the complicated payer credentialing and enrollment process to be a burden on your practice. The credentialing experts at TriZetto Provider Solutions have experience working with various payers and providers of all backgrounds. TriZetto will collect and submit information in a timely manner and perform all necessary follow-up tasks. Together, Criterions and TriZetto will lighten your load so you can focus on patient care and growing your practice.

Have any questions about credentialing? Contact us using the form below:

Request a Demo!