Section : Business Information
In this section you have to confirm either you are working under your private practice or you have assigned your benefits to any other private practice.
On the basis of type of practice you work and if all or some of your benefits have been reassigned, Medicare form ask you to fill certain parts about the setting you are working in.
How To Become A Medicare Provider
If you have completed your medical education, training and other requirements and you are ready to jump in serving the humanity at your own. Then, its time to know how to become a Medicare provider.
The answer is very simple. You need to enroll with Medicare in order become a Medicare provider. Here is main question. How to get enrolled with Medicare?
First step is to complete CMS 588i form and thats what I am going to explain in you in this guide.
I have walked the walk on behalf of many physicians. Therefore I will be sharing with you the same strategy. This will definitely help you to become a Medicare provider in shorter period of time.
Lastly, I just want to reconfirm that this guide is solely focused on paper based Medicare enrollment process for individual physician & non-physician practitioners where CMS 855i is used.
Medical Credentialing: How It Works And What It Costs
Credentialing is a term for a process that consists of two parts, credentialing and privileging. Credentialing is the verification of competency, as demonstrated by education, training, licensing and work experience. Privileging is the granting of approval for a healthcare provider to perform certain procedures based on the demonstration of competency.
Also Check: How Much Are Premiums For Medicare
Why Is Credentialing So Important
Credentialing is the healthcare industrys best way to protect patients. It is a way to ensure that patients receive high-quality care from physicians who have met state licensure and certification requirements.
But what about physicians that own their own practice? If you dont work for a hospital or another doctors practice, do you need to be credentialed?
If you want to accept health insurance from patients, the answer is yes.
Insurance companies will not pay claims unless the physician is already credentialed. Like hospitals and large healthcare groups, credentialing is also used by insurance companies. It is another way for insurance companies to make sure that they are paying legitimate, licensed physicians.
Credentialing is a requirement if you wish to bill through Medicare and Medicaid.
Through credentialing, health groups verify that you have completed your medical training. They do this by looking at your diplomas, licenses, and certifications.
They also look to see if you have any pending medical violations.
Physicians will have to undergo credentialing many times throughout their careers. It is common for hospitals and healthcare organizations to re-credential every two years.
Keep in mind, credentialing isnt just for physicians working in hospitals. Almost every healthcare facility, urgent care clinic, and long-term care facility requires credentialing.
Related: Physician Employment and Partnerships: Evaluating Options
What Is Medicare Credentialing
Medicare providers serve Medicare beneficiaries and are paid for their services by Medicare instead of by the individuals. Medicare approves a variety of individual practitioners, agencies and facilities to provide high-quality care to Medicare recipients. Medicare credentialing standards vary depending on the type of services you are providing.
TL DR
Credentialing is the process of approving a physician, agency or other medical provider as part of the Medicare supply chain.
Recommended Reading: Can I Buy Into Medicare
Entities That Regulate Or Provide Standards For Credentialing Of Providers
The federal Centers for Medicare & Medicaid Services and the Joint Commision on Accreditation of Healthcare Organizations both require that healthcare providers be credentialed. Healthcare organizations that dont follow the CMS regulations are not eligible for Medicare or Medicaid reimbursement. Similarly, the Joint Commission accredits only those who follow its regulations. Most U.S. hospitals pursue the Joint Commission accreditation, which is required for Medicare and Medicaid reimbursement eligibility. States also have their own regulations.
Other groups set standards on credentialing as well, and many healthcare organizations follow them to receive additional accreditation. Those groups include the following:
- The National Committee for Quality Assurance
- Utilization Review Accreditation Commission
- The Accreditation Association for Ambulatory Healthcare
- Det Norske Veritas
What Nurse Practitioners Need To Know About Credentialing
When I was offered my first job in the emergency department, I assumed the transition would be smooth. After all, I was no longer a new graduate so my certification, licensure, and DEA number were all in order and ready for action. All I had to do was look over my contract and sign on the dotted line. I didnt even bother to negotiate . But I was wrong.
ThriveAP Intern Stephanie Bauer has used her administrative healthcare know-how to give us some insight into what nurse practitioners need to know about the NP credentialing process. Take it away Stephanie
The Process of Getting Credentialed for Your Nurse Practitioner Job
What does it mean to be credentialed as a healthcare provider? What about being certified? While the names are similar, the two are not the same thing. Healthcare certification is defined as official approval to do something legally or professionally. This is what you get when you pass your boards, or nurse practitioner certification exam. Credentialing is a system used by various organizations and agencies to ensure that their healthcare practitioners meet all necessary requirements and are appropriately qualified. Credentials are very specific to the type of provider and specialty.
The credentialing process involves the verification of education, licensure, certification, and reference checks. In order for a nurse practitioner or physician assistant to be eligile to bill government agencies and insurance companies, they must be credentialed.
Don’t Miss: Is Nano Knee Covered By Medicare
Applying For Medicare As Your Primary Coverage
If Medicare will be your primary coverage, you should enroll in Medicare in the 3 months before your birth month. Your Medicare will start on the first of the month in which you turn 65. Enrolling prior to your birthday will ensure your benefits begin on the first of your birthday month.
If you register for Medicare in the 3 months after your 65th birthday, then your start date will be later. People unaware of this could end up with a few months of no health coverage. Its important to realize that your application date affects your start date.
Also, if you are leaving employer coverage in the middle of your Medicare Initial Enrollment Period, then your IEP trumps any other election period. Weve seen this a number of times where people assume their Medicare coverage will start immediately after the group coverage ends.
However, if you are in your IEP and your birth month has already passed, this chart demonstrates that you must wait for your coverage.
Its easy to see why applying for Medicare prior to your 65th birthday month is generally in your best interest. Although, it is ultimately your choice on when to apply.
Applying During the General Enrollment Period
Medicare Enrollment and Small Employer Coverage
Phase One: Study And Preparation
To complete stage one of pursuing medical billing certification, you must complete three tasks. They are:
1. Choose Your Acronym: First, decide on which medical biller certification you want to earn. Then, research how to fulfill the requirements of your chosen credential. Two of the major medical billing certifications are:
- Certified Medical Billing Specialist from the Medical Association of Billers . $199 fee.
To receive certification through either of these organizations you will need to pass a comprehensive exam. Both exams cover similar subject matter, such as:
- medical terminology
- Medicare and private insurance claim processing guidelines
- handling denials and appeals
- maintaining regulatory compliance and avoiding accusations of fraud or abuse
2. Uncover Resources: Once youve decided on your desired certification, seek out relevant resources to help you prepare for the exam. Some students complete self-study with the help of textbooks, while others enroll in online courses or seek the guidance of classroom-based preparatory classes led by trained instructors.
The average time frame for completing a preparatory course is three to six weeks, though you may find shorter and longer programs. Many online certification courses allow you to study at your own pace, so you determine the amount of time you have available to complete the coursework.
Read Also: What Is A Medicare Claim Number
How Long Does It Take
This is the most frequently asked question by our clients who avail of credentialing service. What is the Physician Credentialing Process? How much time is it going to take for the application to be processed? The time taken for this is dependant on many variables that will affect the timeline. Predominantly it depends on the type of enrollment being sought.
Credentialing is a systematic process of verifying healthcare providers educational documents, competence, certifications, experience, or status of the current licensure. Insurance carriers, employers, and Hospitals require this background check to decide about provider enrollment.
The credentialing process can take a lot of time because it involves extensive documentation in the first phase and then it depends on how long the payor or carrier would take to check your application. Compared to commercial carriers it is faster to get enrolled with Medicare.
Between 40 to 60 days is the time that it takes to get enrolled with Medicare on average. However, getting registered with commercial carriers can be hectic and can take up to 90 120 days on average. There are some other dependencies too that can delay the process.
Non-credentialed physicians cannot be billed for practices. Any claims submitted on behalf of such a physician would result in denial. Occasionally, claims of a non-credentialed physician are submitted in the name of an already credentialed physician by practices.
How To Get Credentialed
The first step in getting credentialed is to know the regulations in your state. The application, verification, and approval process can take between 90 and 150 days.
If you need physician credentialing before starting a new job, dont wait. Start the process as early as possible.
Heres to how to handle the process from start to finish:
You May Like: How Much Does Medicare B Cost
What Are The Advantages Of Medical Credentialing
Medical credentialing provides quality assurance to the medical industry, which benefits all parties involved. Hospitals and clinics can be confident that the staff they hire will provide care at the standards demanded of them. Insurance companies have an incentive to keep their costs down and therefore prefer to ensure only those professionals who demonstrate sufficient competence to practice medicine.
Practitioners benefit from medical credentialing because once they receive privileges to accept clients from insurance companies, they can expand the number of patients who have access to them. Finally, patients get perhaps the greatest benefit of all, the knowledge that the medical industry is maintaining rigorous standards to ensure that the health care that patients receive is of the highest quality.
The advantages of medical credentialing are that it maintains confidence in the quality of the medical professions, minimizes medical errors and keeps costs down. This system makes sure that everyone is better off.
How Medical Credentialing Works
Medical credentialing is a market-driven process that seeks to maintain standards of quality in the medical community for the benefit of patients. The process involves direct contact with primary sources for the verification of a healthcare providers qualifications. The credentialing authority will contact the university where the provider received their degree in medicine, had their training, and did their residency, to confirm their credentials.
They will also contact certification boards and licensing agencies to verify licenses and specialty certificates. Hospitals and other employers can provide confirmation of work history. Credentialing is important for all new hires, but it is performed at regular intervals even after hiring to conform to the standards of regulatory and accrediting organizations, like The Joint Commission , The Centers for Medicare and Medicaid Services , and the National Committee for Quality Assurance .
Don’t Miss: Can I Get Glasses With Medicare
Section : Managing Employee Information
Provide information about the employee who is responsible for handling day to day operations of your private practice.
Skip this section if you have reassigned all your benefits to other private practices or you work under you own medical practice setting but you are one who manage the practice operations.
Skip this section if you handle you billing yourself or you are reassigning 100% of your Medicare benefits.
How Much Does Medical Credentialing Cost
Medical credentialing costs vary from specialty to specialty, from facility to facility, and from CVO to CVO. Typically, an application fee of two or three hundred dollars is not out of the ordinary. Often, facilities will offer reimbursements or partial reimbursements upon successful completion of credentialing.
After the initial credentialing, periodic re-credentialing will be necessary, and CVOs usually provide this at a discounted rate.
Also Check: What Is The Difference Between Medicare
Applying For Medicare When You Have Large Employer Coverage
Medicare can coordinate with your employer insurance even if you or your spouse are still working. If you or your spouse are actively working at an employer with 20+ employees and you are covered by that insurance, Medicare will be secondary to the employer coverage.
In that case, you can choose whether to enroll in Medicare Part B or delay your enrollment into Part B until later. Your group health plan likely has coverage for medical services already built in, so delaying Part B enrollment can save you money until you retire from your job.
When to apply for Medicare varies for each person. Whats worse is that even though these rules exist, there are often workers at Social Security who will get them wrong. This can really affect you, so contact a Medicare insurance broker like Boomer Benefits for help. We have solved Medicare enrollment issues for our clients with plain facts in many conference calls with Social Security.
Lastly, if you are still working at 65, well evaluate the costs of your employer coverage compared to Medicare. If staying at your employer insurance makes more sense, we can help you decide whether to enroll in Parts A or B or both.
Please note, you will qualify for a Special Enrollment Period after 65 and will need to submit documentation when you apply for Medicare due to loss of employer coverage. The two documents include CMS form 40B and CMS form L564 which is your proof that you had creditable coverage during employment.
What Is Primary Source Verification
Primary source verification means that a CVO will verify credentials directly with the source of those credentials. In order to prevent any sort of fraud in the credentialing process, no documents from the applicant nor from any other third-party source are considered acceptable. A CVO will contact The Board of Medicine directly to confirm a medical license. Strict adherence to this standard is essential to maintaining certification for healthcare facilities, as well as simple common-sense best practice.
Don’t Miss: Are Blood Glucose Test Strips Covered By Medicare
When To Apply For Medicare
Medicare is separate from your application for Social Security income benefits. People age into Medicare at age 65, regardless of whether they are taking retirement income benefits yet. If you are a citizen age 65 or older and need medical insurance, you are entitled to enroll in Medicare. You can also qualify for Medicare early due to certain disabilities, having Amyotrophic Lateral Sclerosis , or End-Stage Renal disease and need a transplant or on dialysis.
Dont expect that Medicare will notify you of when its time to sign-up either. This can be especially important for those who live out of the country.
If you are already taking Social Security income benefits or Railroad Retirement Board benefits, you will be automatically enrolled in Medicare Parts A and B at age 65. Your card should arrive 1-2 months before you turn 65. This timeframe also applies to those who qualify early due to disability. However, you will not automatically receive Part B benefits if you live in Puerto Rico. This means you will need to apply for Part B even if you receive Social Security benefits before age 65.
If you are NOT yet taking retirement benefits, then you will need to submit a Medicare application yourself. The government expects for you to know when to enroll. Lets look at the timeline for when and how to register for Medicare.
Don’t Give Personal Information To Plan Callers
Medicare plans aren’t allowed to call you to enroll you in a plan, unless you specifically ask to be called. Also, plans should never ask you for financial information, including credit card or bank account numbers, over the phone.
No one should call you without your permission, or come to your home uninvited to sell Medicare products. Call 1-800-MEDICARE to report a plan that does this. Learn more about how to prevent Medicare fraud and abuse.
Read Also: What Is Medicare Part F Supplemental Insurance
Streamlined Credentialing For Medicaid Providers
The Agency for Health Care Administration has created a streamlined application, or Limited Enrollment, for providers who do not hold a Medicaid ID and need to complete basic credentialing which may be a prerequisite to seeking a contract with a Medicaid health plan.
With the implementation of Limited Enrollment in December 2015, providers seeking to participate in a health plans network have the option to utilize a web-based Limited Enrollment application wizard which guides them through creation of the application. The streamlined application and corresponding review process allows approved providers to receive their Medicaid IDs faster than with traditional full enrollment.
Upon receipt of a Limited Enrollment application, AHCA will perform several basic credentialing functions, including licensure verification and review of background screening history, including criminal history and federal exclusion database checks.
Successfully obtaining a Limited Enrollment status with Medicaid may eliminate the need for providers to undergo the basic credentialing with each plan with which they seek to contract and may reduce the time it takes for a plan to complete credentialing with a health plan.
NOTE: Assignment of a Medicaid ID does not guarantee a place in the network of any health plan. Each plan may apply their own standards for provider credentialing beyond what is required by Medicaid.
