Credentialing is a critical process for healthcare providers, yet it often comes with a myriad of confusions that can significantly impact your practice’s operations and revenue. Here, we address three common areas of misunderstanding in credentialing and provide clarity to help you navigate these challenges effectively.

Disassociating from Former Groups or Employers

One of the biggest confusions arises when providers transition from working within a group to starting their own practice. If you were previously credentialed under a group’s Tax ID, you must ensure you disassociate from that group’s credentialing. Failing to do so can result in being mistakenly listed as in-network under your old group, leading to billing issues and potential revenue loss.

To avoid this, contact each payer to disassociate your credentials from the former group and associate them with your new practice’s Tax ID. Note that even if payers honor your individual credentialing, updating your information can still take at least 30 days.

Differentiating Between Credentialing and Contracting

Credentialing and contracting are two distinct steps in the process:

• Credentialing involves verifying your qualifications and background to ensure you meet the standards to be considered in-network. This step includes validating your education, work history, and malpractice coverage.
• Once credentialed, the next step is contracting. This involves establishing a contract between your practice (or you as a sole proprietor) and the payers. The contract will be associated with your practice’s Tax ID and NPI number, and will include details of all providers billing under that contract.

This dual-step process can take 90 to 120 days or longer if re-credentialing is required.

Understanding Effective Dates

A common misconception is that the contract becomes effective on the date it is signed. However, most contracts specify an effective date, often set a month or two after signing to allow payers time to update their systems. It is crucial to verify this effective date to avoid seeing patients as out-of-network before the contract takes effect.

Additionally, inquire whether payers allow retroactive dating of claims to cover services rendered before the effective date. Many plans do not allow retroactive claims, meaning any services provided before the contract’s effective date could be processed as out-of-network, potentially resulting in denied claims or out-of-pocket costs for patients.

Conclusion

Ensuring a smooth credentialing and contracting process involves careful attention to disassociating from previous groups, understanding the sequential steps of credentialing and contracting, and clarifying contract effective dates. By addressing these common areas of confusion, you can better prepare your practice for successful operations and avoid potential financial setbacks.

For expert assistance with your credentialing needs, visit Physicians Credentialing. Our experienced team is here to support you through every step of the process.

For more insightful articles on credentialing and healthcare practice management, explore our blog section at Physicians Credentialing.