Establishing the Optimal Formation

EPISODE SUMMARY

Join Jeremy and Kathryn Zug in this tactical episode of The Claim Game as they dive deep into the initial stages of the credentialing process: information gathering and application completion. This episode is packed with essential tools and strategies, moving beyond a general overview to provide clear, actionable steps for practice owners and administrators. Kathryn outlines precisely what practice and provider information to collect, how to organize it, and when to consolidate these crucial documents. You'll learn the importance of having supporting documentation, understanding CAQH, and meticulously tracking application statuses to avoid costly denials. Jeremy shares a compelling case study about a clinician who faced significant revenue loss due to improper credentialing, underscoring the critical need for preparation and documentation. Get ready to take decisive control of your practice's financial health by mastering these foundational credentialing steps.

KEYWORDS

Credentialing , Revenue Cycle Management , RCM best practices , Insurance billing , Practice management , Healthcare administration , Payer contracts , CAQH , NPI , EIN , CPT codes , Timely filing , Claim denials , Patient care , Practice Solutions , Hourglass Learning Hub

TAKEAWAYS

Information Gathering is Key: Understand when (ideally before employment or within the first week ), how (sit with an admin ), and what information to collect for both your practice and individual providers.

Consolidate Practice Information: Maintain a single document for your practice's legal business name, owner's names, articles of organization, address, start date, Type 2 NPI, EIN, liability insurance, bank information, contact details, office hours, CPT codes, and disabled accessibility information.

Provider Information is Comprehensive: Be prepared to collect full legal names, driver's licenses, Type 1 NPIs, SSNs, professional licenses, educational details, professional references, CPT codes specific to the provider, and criminal/civil history.

CAQH is Vital: CAQH is a central hub for insurance companies to verify provider credentials and can save you time by consolidating information. An admin can sit with the provider to ensure thorough and consistent completion.

Verify Existing Credentialing: Before submitting new applications, always confirm if a provider is already credentialed with any of your practice's payers, as submitting a full application unnecessarily can cause major delays or issues.

Document Everything Meticulously: Use tools like a credentialing application follow-up log to track the status of each application. Create a payer list chart with portal links, application links, and change form files. These documents are crucial for efficiency, long-term KPI tracking, and seamless transitions when staff changes occur.

Read Applications Carefully: Always review applications thoroughly before submission to ensure all boxes are checked and information is accurate to avoid costly denials and "free work".

Understand Your Credentialing Matrix: Know exactly how you're credentialed with specific plans within insurance companies, not just the company name, to prevent unexpected carve-outs that lead to unpaid services.

Preparation and Documentation Prevents Loss: Inadequate preparation and documentation can lead to significant revenue loss, as highlighted by the case study of a clinician losing months of services due to improper credentialing.

CHAPTERS

00:00 Introduction to Credentialing in Revenue Cycle Management

03:47 Stage 1: Information Gathering - What to Collect for a Practice?

08:14 Stage 1: Information Gathering - What Practice Information to Collect? (Continued)

10:08 Stage 1: Information Gathering - When to collect this information?

11:51 Stage 1: Information Gathering - Who Collects this Information?

13:25 Stage 1: Information Gathering - What Provider Information Do I Collect?

21:00 Stage 1: Information Gathering - Summary

22:12 Stage 2: Application Completion

29:00 Case Study Card: 

33:25 Summary of Stages 1 & 2

34:20 Introduction to The Claim Game Podcast

34:48 Engagement and Feedback from Listeners

35:16 Resources and Educational Opportunities

RESOURCES

Learn More About The Claim Game: Visit practicesol.com/theclaimgameThe Hourglass Learning Hub: Dive deeper into RCM best practices and downloadable tools mentioned in this episode, like the various checklists and templates, by visiting .css-j9qmi7{display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-flex-direction:row;-ms-flex-direction:row;flex-direction:row;font-weight:700;margin-bottom:1rem;margin-top:2.8rem;width:100%;-webkit-box-pack:start;-ms-flex-pack:start;-webkit-justify-content:start;justify-content:start;padding-left:5rem;}@media only screen and (max-width: 599px){.css-j9qmi7{padding-left:0;-webkit-box-pack:center;-ms-flex-pack:center;-webkit-justify-content:center;justify-content:center;}}.css-j9qmi7 svg{fill:#27292D;}.css-j9qmi7 .eagfbvw0{-webkit-align-items:center;-webkit-box-align:center;-ms-flex-align:center;align-items:center;color:#27292D;}