Missing Piece Blog

What Navigating Credentialing Means For Your Business

For many care providers, navigating credentialing is one of the more complex aspects of establishing and growing your practice.

What is credentialing in medical billing? The credentialing process in medical billing is the process that payers use to verify that a practice or provider meets specific standards. The payer establishes those standards, which typically involves verifying that the provider has proper licensing and certification, along with other requirements.

Credentialing is critical for payers, as it helps them ensure they are providing payment to qualified professionals. It’s a necessary step to ensure you can provide quality care to your patients.

The difference between credentialing and contracting

Credentialing and contracting are two fundamental processes in the administration of ABA therapy practices, but they serve distinct purposes. Credentialing involves verifying the qualifications, experience, and professional history of ABA therapists to ensure that they meet the required standards set by healthcare organizations and regulatory bodies. What are credentials? This process includes checking educational background, licensure, certifications, and any potential disciplinary actions. Effective credentials ensure that the therapists providing care are competent and qualified to deliver high-standard services.

On the other hand, contracting refers to the process of establishing formal agreements between ABA therapy providers and payers, such as insurance companies or government programs. These contracts detail the terms and conditions under which services are to be provided, including payment rates, billing procedures, and the scope of services covered. Contracting is crucial for securing financial reimbursement and enabling access to therapy for clients under various insurance plans.

While credentialing focuses on the qualifications and integrity of the practitioners, contracting sets the operational framework for delivering and funding therapy services. Both processes are essential to maintain the quality and accessibility of ABA therapy services.

What does credentialing entail?

The credentialing process can be long and overwhelming. Each of the insurance companies you hope to be credentialed and contracted with sets specific requirements for the process. They also require numerous steps to provide information and verify your qualifications and business credentials. It can take between 30 and 180 days (and sometimes longer) for the process to go through. If a mistake occurs and the proper steps are missed, a client’s claim for care may be denied, putting your practice at risk.

The most important step to ensuring a swift and streamlined credentialing process is to get a proper handle on the supporting documentation required. You’ll need to submit a variety of different supporting documents as an ABA provider. They include, but are not limited to, the following:

  • Copies of qualifications, accreditations, and certifications, such as degrees and diplomas
  • Your resume, including your work history
  • Proof of professional liability insurance
  • A detailed description of the medical services provided

Unfortunately, if any of the required documents are missing, you’ll usually have to start your application from scratch. 

Re-credentialing is another process to keep in mind. For example, Medicare insists on re-credentialing on a five-year basis, while most other insurance companies require updated credentialing every two years. Be sure to read the fine print in your approval letter if in doubt regarding re-credentialing requirements and keep an eye out for a notification email. It’s vital for you to adhere to the stipulated time frames to avoid losing your NCQA accreditation. 

What if your credentialing application is rejected?

There are a few reasons why your application might be denied. For instance, denial is most common if the payer is unable to verify the completion of a training program. Other reasons include problems with verifying any other details documented and submitted on the provider application, or failing to release sanctions, adverse actions, or limitations. In rare cases, an application is rejected by accident. 

If you receive a denial and you’re fairly certain it was due to an error on the payer’s part, it’s possible to appeal following the payer’s unique appeals process. If the denial remains in place, you’ll have the opportunity to re-apply after a time-lapse of typically between one and three years following the date of your original application submission. 

The benefits of ABA credentialing services

Handling your practice’s credentialing in-house means staying organized and on top of the ever-changing medical billing and coding credentials requirements from payer to payer. It means keeping up-to-date folders and logs detailing where you are in the process of approval for each payer to which you’ve applied, as well as when re-credentialing is required. In most cases, you’ll need to hire an ABA credentialing expert to guide the process. Experts like these are expensive and hard to find, which is why it’s usually more convenient and affordable to outsource and make use of ABA credentialing services.

Working with a third party specializing in business credentialing services, such as Missing Piece, could make the ABA credential process easier. By working with an experienced provider in ABA credentialing, you’re less likely to make mistakes that could cost you time and money.

Missing Piece can handle the documentation and all paperwork necessary for credentialing. That way, you can continue to focus your time on providing care for your patients and the services you know they need.

Our team can also handle the entire review process for insurance companies. This may include verifying licensing and certifications. In addition, any questions or concerns can be quickly addressed and handled by a team of qualified professionals.

In some situations, the credentialing process requires just one step: a one-time process of establishing a contract with the payer. Other times, it can involve a lot of back-and-forth and numerous questions, steps, and concerns that need to be addressed. There’s no way to know what’s going to happen until you begin the process. It’s always better to be well-prepared and properly equipped to deal with any worst-case scenario regarding applications. 

Missing Piece can take care of the necessary tasks, including handling the re-approval process exactly as the insurance company requires.

Providing comprehensive services for providers

Missing Piece can narrow down and work through timelines with ease. Our team can research and onboard new providers efficiently. Using our ABA credentialing services, providers know that the correct documentation is being provided, even as laws continue to change within the industry.

With experience working with most insurance providers, Missing Piece can effectively eliminate the risk of complications during the process. If there is a need for more information or data, it’s all taken care of on your behalf.

Maintaining credentialing

Rectifying the loss of credentialing with an insurance provider can be a costly and time-consuming process. When you work with a credentialing team, you don’t have to worry about losing patients due to a credentialing lapse, and your patients don’t have to wonder if they can continue care. Missing Piece ensures that ongoing credentialing is maintained throughout the life of a contract.

Protect and grow your practice with Missing Pieces’ expert services

Handling the credentialing process on your own is no longer necessary. Missing Piece’s experience and expertise in this area can serve as the backbone for your organization’s credentialing. Plus, outsourcing these services can help minimize risks while ensuring your time is focused on patient care. Learn more about why you should outsource medical billing to Missing Piece and explore the benefits of how outsourcing can improve your practice management. Contact us to discuss your needs or to schedule a free billing analysis.