So you hired a credentialing company and you finally received notification that your credentialing has been completed. You are so over the moon excited and cannot wait to submit all of the claims you’ve been holding for months! What a glorious day, right?
Thirty days go by and you begin receiving denials on all of your claims or worse yet, you still haven’t heard anything. Even worse, maybe your claims were rejected at the clearinghouse level (front-end rejections). You are at a loss and you just don’t know what to do!
How could your credentialing company do this to you?! It can’t be true, right?! It must be a mistake. Well, maybe not. Let’s talk about the differences between credentialing versus contracting and why you may be receiving these denials.
Credentialing
Credentialing is a term used in our industry to signify that the insurance payor has received and has verified all of your documentation such as NPI, Tax ID, Medical Licensures and so on. When a payor says you are now “credentialed” they simply mean they have: 1) received all required paperwork and applications and 2) have now deemed you or your group fit for contracting. It DOES NOT mean you are ready to submit claims in most cases.
Contracting
Contracting is a term used to signify that your credentialing process has been completed and your file has now been sent to the Contracting Department for review. The Contract Department will review your taxonomy codes(s) to determine your specialty. For instance, if you are an OBGYN they will know this based off of your taxonomy code. Making sure your taxonomy code is up to date is a key factor in the credentialing process. A good credentialing company will have verified this information early in the process.
Now that the contracting department knows you are an OBGYN they will create a contract specially centered around OBGYN codes and standard medicine codes such as E/M (evaluation and management) codes. Once they create this contract with all CPT codes they will then give each CPT code a price. This price may be listed next to each code or you may be paid on a percentage scale (i.e. 120% of the 2015 Medicare fee schedule). Now that the payor has made a contract for you they need to send it to you for review. Hence, the reason why your claims are NOT yet ready to be sent out.
What now? Once you receive your contract you will need to sign it. This copy of the executed contract will be sent back to the payor. Now hold your horses! Just because they received the executed copy of the contract does not mean you are ready to submit claims. The payor must now load the contract into their software with your NPI and Tax ID number etc. so that the claim software can adjudicate (pay) your claims. Once you receive notification from the payor that you are contracted, and your contract is loaded, you may now, FINALLY, begin to submit your claims.
If you are suffering from payor denials, reach out to a qualified credentialing expert to help you finalize (or fix) the credentialing and contracting processes.
Cynthia Young, the former CEO of STAT, which a U.S.-based, national provider of credentialing, payor enrollment, rate negotiation and other credentialing related services.