Credentialing Effects on Reimbursements for Orthopedic Practices

Billing & Reimbursement Health Information Services Practice Management

credentialing Orthopedic practices often suffer from revenue stream issues stemming from a number of different causes. The reimbursement process is complicated enough without holding it back due to issues within a practice, and yet there are common concerns which plague orthopedic practices if not carefully monitored. One of these issues is the credentialing process for providers.

Credentialing and Privileges

The surgeons of most orthopedic practices operate at multiple healthcare facilities – clinics, hospitals and ambulatory surgery centers (ASCs). When adding an new orthopedic surgeon to the physician staff of a practice, that new provider must become credentialed through each facility in order to obtain privileges to practice at the hospitals and/or ASCs being applied to, and to receive reimbursement for the services from the insurance carriers.

The process of getting credentialing thoroughly in place involves a lot of materials and paperwork, not to mention what can become a rather lengthy follow-up process between the practice, the healthcare facility, and the payers. 

Complete the CAQH paperwork

When applying for privileges at a healthcare facility, they will generally require the CAQH (Council for Affordable Quality Healthcare) application for credentialing to be filled out as part of their application process. The Universal Provider Datasource (UPD) is a data base within CAQH which is accessible by healthcare facilities and insurance carriers. The UPD serves as a single data storage location which eliminates the need to submit the same information to all the different facilities and carriers involved. The CAQH application is many pages long, requires a lot of attachments verifying education and experience, and would be better completed online for the sake of efficiency. 

Follow up with the facility

Keep in mind that each healthcare facility may handle a high volume of applications and related paperwork. It is important to stay in close contact with the facility to be sure that the application is in order and is being processed in a timely fashion. This is far too important a situation to leave it up to others who are likely overwhelmed by a large workload. Persistence is key.

Be sure to call or email for confirmation of the receipt of any documents you’ve sent over to the facility. Keep in mind that the entire process of becoming credentialed and obtaining privileges can take as long as 90-120 days from start to finish. You will need to check in periodically once you know that all of your documents have been received and are in order to make sure the approval process is moving along and that your application hasn’t somehow fallen through the cracks. After too much time has passed, an application can expire – and you wouldn’t want to have to start from scratch.

While the process of getting credentialed is tedious and time-consuming, neglecting is not an option. Without being properly credentialed, the provider will not have privileges to practice at the various healthcare facilities. Without privileges the provider cannot practice or provide services for which to be reimbursed.

Consider getting help

In a small to mid-sized practice, where adding new physician, mid-level provider and therapy staff members is an infrequent event, hiring an outside service may help greatly. Not only can a reputable, experienced service help alleviate the stress and frustration of going through the process of getting a provider credentialed, they can also potentially save you time and money in the long run. There are many reputable firms out there that offer this as a stand-alone service or you can partner with a firm who provides this service as a part of the overall revenue cycle management strategy.

Healthcare Information Services (HIS) is a full service revenue cycle management company and we are very experienced with the credentialing process. We can help you navigate the issues that the process entails and can be reached at (855)RING-HIS.