Initiating the Game

EPISODE SUMMARY

Welcome back to The Claim Game! In this episode, Jeremy and Kathryn Zug zoom into the first critical "territory" on your Revenue Cycle Management (RCM) game board: Credentialing. This process is your entry point to accepting insurance, and understanding its nuances is key to your practice's success. The Zugs break down the decision between handling credentialing yourself (DIY) or outsourcing to a specialized service, exploring the pros and cons of each approach to help you choose the best path for your practice.

They then guide you through the six stages of the credentialing journey:

Stage 1 - Information Gathering: The foundational phase of meticulously collecting all necessary practice and provider data, often utilizing platforms like CAQH.

Stage 2 - Application Completion & Submission: Filling out forms with painstaking attention to detail, ensuring everything matches your supporting documentation.

Stage 3 - Application Follow-Up: An active and ongoing process of consistently tracking your application's status, confirming receipt, and proactively resolving any flags or denials.

Stage 4 - Contract Finalization: The crucial step of carefully reviewing and understanding your payer contract's terms, responsibilities, and compensation details before signing.

Stage 5 - Start Date Establishment: Understanding that your official in-network status begins on your effective date, not just upon contract signature.

Stage 6 - Manage & Review: Recognizing that credentialing is an ongoing cycle, requiring regular recredentialing/reattestation and updates to your information.

Even if this sounds like a lot, Jeremy and Kathryn assure you that understanding this "bedrock" process empowers you to navigate it successfully and build the practice you envision.

KEYWORDS

Credentialing , RCM , Revenue Cycle Management , Payer Selection , DIY Credentialing , Outsourcing Credentialing , Practice Management , Healthcare Billing , Insurance Billing , CAQH , Information Gathering , Application Submission , Application Follow-up , Contract Finalization , Start Date , Manage and Review , Recredentialing , Reattestation.

TAKEAWAYS

Understand Your Credentialing Options: Decide between handling credentialing in-house (DIY) or outsourcing to a specialized service, weighing control and cost against experience and bandwidth.

DIY Pros & Cons: DIY offers more control and customization, and internal staff can become highly efficient, but it demands time, learning, and meticulous attention to detail.

Outsourcing Pros & Cons: Outsourcing provides experience, especially for new payers, but can be expensive and may lead to less direct control or transparency on progress.

Meticulous Information Gathering is Key (Stage 1): The initial phase of collecting comprehensive practice and provider information (especially via CAQH) is the bedrock of your application; don't cut corners here.

Proactive Application Follow-Up (Stage 3) is Vital: Don't just submit and forget. Consistently follow up (e.g., every two weeks after initial confirmation) to track progress, resolve issues, and avoid delays in the "waiting game".

Review Your Contract Carefully (Stage 4): Once approved, meticulously review the payer contract for responsibilities, terms, compensation details (including fee schedules), timely filing, and credentialing identifiers before signing.

Start Date is Your Green Light (Stage 5): Your effective start date, not the contract signature date, is when you are officially in-network and can begin seeing patients and submitting claims for reimbursement.

Credentialing is an Ongoing Process (Stage 6): It's not a one-time event. Regularly manage and review your credentialing status through recredentialing/reattestation and keep your CAQH information updated every 6-12 months.

Understanding the Process Empowers You: Even if you outsource, understanding each stage of credentialing helps you manage expectations, ask the right questions, and ensures smoother overall RCM processes.

RESOURCES

Learn More About The Claim Game: Visit practicesol.com/theclaimgame

The 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;}