Credentialing

Larger Reimbursements • New Patients

The National Committee for Quality Assurance [NCQA] sets the standard for credentialing in managed care. Credentialing is the process by which a Managed Care Organization [MCO] authorizes, contracts with, or employs practitioners who are licensed to practice independently to provide services to its members.

Members Include
Each managed care organization (HMO/PPO) sets its own qualifications and then structures its processes to ensure that the practitioners meet these qualifications. Once credentialed, a practitioner must be re-credentialed at least every three years to comply with the state and federal regulations which govern MCO's operations.

Many practitioners do not want to become members of an MCO because they are frugal with the amount of money they allow for medical procedures and can be slow to reimburse, some just don't have the time to jump through the series of hoops required for membership, and a few find the whole process confusing. Unfortunately, providers who have not qualified for, and are not members of Managed Care Organizations do not get fully reimbursed by insurance companies for their services. At best insurance companies will only reimburse 70% of the charges to non-participating providers, however some will only reimburse 30%; which leaves the patient responsible for payment of the remainder. In many cases practitioners and healthcare facilities alike are losing patients who don't want to get stuck with the huge co-insurance amounts, however in some cases they're not. It's a lose–lose–lose situation.

Credentialing is critical for optimizing the Revenue Cycle of any healthcare entity. Our Credentialing Specialists at AccuProfit Solutions can navigate physicians and healthcare facilities through the processes toward getting their applications approved by the Chief Medical Officer [CMO] of however many MCOs (HMOs/PPOs) they would like to become a member of.

Requirements

• Valid and Current Licensure
• Clinical Privileges at a Hospital
• Valid DEA or CDS Certificate
• Appropriate Education & Training
• Board Certification
• Appropriate Work History
• Malpractice Insurance
• History of Liability Claims

Our specialists can also assist in getting practitioners and facilities re-credentialed. Don't throw additional profits away any longer. APS' highly experienced Credentialing Staff will hurdle every obstacle in their path on your behalf. We will get the job done for you.

Contact APS for additional information on our Credentialing Service.