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6 Things You Need to Know About Provider Credentialing

Sep 16, 2022 3:46:12 PM / by Altruis

FQHC Billing Services

Learn the six most important things a healthcare organization should consider for proper FQHC billing services during the credentialing process.

Are you a Federally Qualified Health Center (FQHC)? Understanding the benefits you receive from working with a FQHC billing services provider is important to ensure proper reimbursement for your healthcare organization.

FQHCs provide vital human services and help maintain the ongoing health of our nation. Their reimbursement structure was established under a 1991 amendment to the U.S. Social Security Act, which gave the U.S. Health Resources and Services Administration (HRSA) the task of overseeing FQHCs and ensuring they remain compliant with relevant laws. 

Currently, there are approximately 1,400 fully-qualified FQHCs in the United States, but there’s always the risk that these facilities will lose their FQHC status due to non-compliance. This results in denied reimbursements, financial instability, and an inability to continue serving vulnerable patients who need healthcare services.

Credentialing is a built-in part of maintaining your FQHC status. It ensures every practitioner and provider is fully qualified to receive payments through FQHC billing services.

Here are the 6 most important things your organization should know about FQHC provider credentialing.

#1. The Submission Deadline is Your Top Priority

When it comes to credentialing, work proactively to prevent credentialing slowdowns that can impact the overall reimbursement timeframe. Make it a top priority to consistently hit the deadline for federal reimbursement submissions. 

FQHCs must follow Medicaid and Medicare claims deadlines, which usually means submission must occur within 12 months of the date of service. Physician credentialing is one of the most common parts of the process that creates slowdowns, so ensure this isn’t a roadblock for your organization.

Physician credentialing can take as long as 180 days in an old-fashioned office with subpar processing practices. However, in an optimized credentialing process that uses proper revenue cycle management, physician credentialing can take place within just 90 days or less.

#2. Digitization Drives the Process Forward

One of the best practices in FQHC billing services is end-to-end digitization. This means every stage in the process is fully digital, from the first intake of patient information through the end of the FQHC reimbursement stage.

Full digitization comes with numerous benefits:

  • Keeps the process running smoothly
  • Eliminates sources of errors, like human keystrokes
  • Tracks transmission/submission to the proper authorities
  • Confirms credentialing
  • Maintains compliance
  • Supports financial stability
  • Supports patient care

Digitization also eliminates last-minute scrambling for information that’s required during the billing and reimbursement process. Instead of hunting for physical paperwork, it’s easy to locate materials in the central digital archive.

#3. New Hires Shouldn’t Slow Things Down

What happens when you hire a new practitioner at your organization? In the world of healthcare reimbursements, new hires come with a complex credentialing process that ensures your practice is qualified to receive Medicare and Medicaid payments.

On top of federal laws, each state has regulations for medical credentialing. Plus, these laws are constantly changing. The credentialing process you followed in the past may already be too outdated to use for future reimbursements. 

To stay up to date, use the Coalition for Affordable Quality Healthcare (CAQH) database of uniform credentialing protocols. Doctors should also keep their information up to date with CAQH, which prevents missing information and facilitates fast reimbursements.

Ideally, the CAQH will always have your current licensure and background information a provider or physician needs for credentialing. Review the database regularly to ensure the information is current and accurate.

#4. Don’t Let Duplications and Errors Persist

Mistakes in your billing process can ultimately lead to reimbursement denials. This is why it’s critical to avoid duplications, missing information, and other errors that introduce reimbursement problems.

Often, these types of errors start early in the process and persist throughout it. For example, if your staff routinely hand-enters information into two different systems, there’s an opportunity for inaccuracies that contribute to repayment denials.

Keep in mind that duplication can, in some cases, work to your advantage in the process. If a newly-hired doctor is already credentialed with CAQH, this information can easily be moved into your system digitally.

#5. Working Proactively Prevents Denials

Credentialing-related denials are on the rise in the U.S. A recent study found that more than half of all healthcare practices have experienced an increase in denials within the past 12 months and up to 85% of all medical credentials contain errors that are bad enough to cause a denial. 

One of the best ways to avoid denials is to take a proactive approach that prevents errors from ever happening in the first place. The National Institutes of Health (NIH) recommends routinely checking 9 key credentialing factors:

  1. Basic criteria. Ensure every new hire satisfies basic criteria before the hire.
  2. Grounds. Create clear grounds for hiring/credentialing based on set criteria.
  3. Speed. Arrange deadlines for fast credentialing, including for temporary/short-term hires.
  4. Standard of care. Ensure practitioners who do not meet standard-of-care criteria are limited from practicing.
  5. Saving lives. Have emergency rules in place for situations that call for life-saving medical intervention regardless of credentialing issues.
  6. Privileges. Decide who is allowed certain privileges and distribute clear rules.
  7. Conduct. Establish a code of conduct with penalties for noncompliance.
  8. Region. Stay on top of federal rules plus rules for your state/region.
  9. Re-application. Create a process for fast re-application after a denial.

#6. You Need a FQHC Billing Services Partner, Not Just a Platform

As you can see, proper credentialing calls for a complex set of rules and procedures, plus a proactive approach that prevents reimbursement issues. The good news is that technology has revolutionized FQHC billing services to make the process faster and easier than ever.

Altruis works as more than just an FQHC billing service. We’re your partner in the reimbursement process. Through thriving partnerships, we accelerate reimbursements, custom-match critical services, and empower organizations to pursue success.


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Topics: Billing Solutions


Written by Altruis

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