Credentialing Corner, Medical Billing

2023 Strategies for Improving Medical Billing Efficiency with Credentialing Services

Medical credentialing and billing have become extremely important for hospital credentialing and a smooth revenue cycle. The medical billing procedure includes keeping track of taxable activities and everything surrounding patient registration from treatment and follow-up for the care they have received. On the other hand, medical credentialing involves the process of verifying the provider’s credentials, education, certification, medical license, and malpractice history. 

But to have quick and error-free claim submission and to manage a complete revenue cycle, hospital credentialing is the essential step. Keep reading to know the effective strategies to help improve medical billing by understanding the medical billing procedure.

Improving Medical Billing Efficacy with Hospital Credentialing

Improving Medical Billing Efficacy with Hospital Credentialing

An authorized organization or an insurance company can only perform medical credentialing. Medical credentialing is necessary for receiving medical reimbursement for the services provided, but once the medical claims are submitted accurately. And these can be done only if the following steps are properly followed;

  • Insurance Policy Verification on the First Visit

Once a patient arrives at the hospital, after taking the policy information of the patient, the front desk staff will ensure that their insurance will cover the treatment required for the patient or the procedure the patient made their visit.

If the verified facility and in-house provider are unable to take the patient at the moment, they will schedule another appointment to cater to the patient in the best way.

  • Patient Registration

Both new and returning patients need to present a health insurance card and an authentic Medicare or Medicaid insurance card or photo ID upon arrival. Patients are then provided with on information documents upon arrival to update or fill in their complete information so that their demographic information is kept relevant.

Then the information is verified as the tracking of the provided information is crucial because rejections of claims for insufficient patient information commonly occur. The revenue generation process starts when the admissions office begins to gather co-payments and additional co-payments from the patient after they have been seen.

  • Super Bill Creation

Once the patient checks out, all the provided treatment documents are translated into codes to bill for the services, procedures, and treatment rendered. The medical coder obtains the individual’s paper chart or electronic healthcare record after interacting with the individual who is being treated. Medical billers translate source services into chargeable codes after collecting notes against the services. Each code has various degrees of treatment and amenities offered.

  • Bills from the Medical Sector

Medical billers then use the data to create medical claims manually or with claims-generating software after collecting the coded document from the coder. The billers from the organization or clinics submit the medical claims to the insurance payer or the Medicaid/Medicaid claim dealing coordinator for reimbursement once all the documentation is complete.

How to make Claims for High-Quality Medicine

How to make Claims for High-Quality Medicine

You can ensure that payments are received on a period of time, maintaining the happiness of patients and reducing the risks of medical fraud by making sure that all the steps of the reimbursement procedure are carried out accurately. The process by which the claims are managed in the healthcare system frequently wants to be improved. Here are a few suggestions for simplifying and improving the management of revenue cycles.

1-         Document the Details for Payment

Once the treatment is completed, a medical biller will put all the information in an electronic health record system (EHR). This information will cover the information about the diagnosis, treatment provided, patient medical history, and the procedure details according to policy. All information will be uploaded directly to the patient records and added to the medical history.

2-         Assigning Medical Code

Many times, electronic health records maintaining software suggest the codes assigned to the treatment or the diagnosis when the information is entered. However, certified providers and coders are allowed to assign medical codes where necessary. These codes minimize the need for lengthy codes and concise the expanded descriptive codes. These codes include ICD-10 and CPT codes and are used for a range of diagnostic procedures.

Through an EHR system, codes are entered to process the claim submission electronically or in a documented form. The concerned authorities can review these claims before they are submitted to payers.

3-         Submitting Claims Electronically

Once the claims are completed, and the treatment is verified, providers or healthcare institutions can opt to submit it either manually or electronically. On the other hand, due to the higher patient turnover and regular medical tasks, medical companies outsource all of these medical billing processes to an authorized medical billing third-party company that takes care of the entire billing process until submissions.

These institutions act as an intermediary and identify coding errors, any missing information or document, and potential mistakes in the claims that may result in reimbursement delays.

  • Keep up with the Most Current Legislation

The work of a coder in the medical field frequently involves the analysis of information. Every operation carried out within the context of medical treatment is given an individual code. To ensure proper billing and the best potential compensation for the healthcare organization or physician, professionals in coding have a duty to code appropriately. To achieve this goal, Staff must stay up-to-date on coding specifications, particularly the constantly updated procedural codes created by the American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS).

  • Claims need to be Swiftly Modified and Re-filed.

Usually, a third party or insurance company will allow the service provider to amend the complaint before completely denying it. Consider implementing a review and resubmission mechanism to save money and accelerate payments. This would accomplish both of the aforementioned goals.

4. Establish the Right Window of Opportunities to Submit an Appeal.

If a medical claim is denied for any valid reason, refrain from being afraid to appeal! If everything is correctly implemented and the payer refuses to pay or delivers a wrong amount, think about filing an appeal. By implementing the two fundamental methods listed below, the doctor treating you may be able to enhance the success of your appeal:

  • Maintain precise documentation of anything.
  • Maintain calmness when bargaining.

It’s best for you to use the terminologies from your contract when preparing the letter of appeal. If the payer over and over misses the payment time constraints, consider completing a prompt repayment appeal. The rules and regulations on timely reimbursement require the amount of time to settle the reimbursement for the claims they have received. Due to the fact that the regulatory and local state regulations vary from one state to another, providers need to understand the whole process of reimbursement for the service they want to provide. The rules and regulations generally notify payers and identify the need for regulatory compliance that can become the reason for delays if they are not met.

5. Stop Billing Customers for Unprovided Services

The expression “bad debt” is utilized by the American Hospital Association (AHA) to refer to services that institutions were expected to provide but did not. In other words, hospitals did not provide the services, but the procedure was planned for the diagnosis. In 2019, the total unpaid care cost was $41.61 billion. Using the techniques mentioned above to persuade patients to settle their bills before the accounts are handed into collections is one way of avoiding bad debt. This is a particular way to avoid negative debt.

Set up a Patient Payment Method on the Website

Set up a Patient Payment Method on the Website

A possible approach that will ease the payment process for both institutions and patients is to incorporate a billing mechanism in your strategy for engagement with patients. For a payment and collection plan to be successful, it is essential to keep a patient’s needs on priority. Most patients (92%) who responded to a Black Book Revenue Cycle Management survey indicated they would like to be able to pay their bills online. 94% of respondents stated that they want more open pricing. Only 23% of patients doubted by PYMTS in 2021 reported making payments through their supplier’s website, despite the service experiencing great demand. Compared with online payment gateways, invoices printed on paper have a higher payment conversion rate. This is because, compared to conventional billing, electronic payment gateways interact with patients online wherever they are presently engaged. Associated with experience in online billing mechanisms is strongly recommended to improve the possibility that the portal for patients that the healthcare organization is currently developing will be profitable.


–       What should a provider do if health insurance claims are denied?

When an insurance claim is denied, providers do not need to panic. Every insurance provider provides an appeal process to request the re-review of the denied claims. The claim submission is undoubtedly a complex and cost-consuming process, but resubmitting the claim to the insurance provider while removing the concerns raised can bring in positive results.

–       How much does a health insurance claim submission cost?

The medical claim’s cost depends on the claim type and the amount to be reimbursed. Not every claim contains cash, and not every claim has reimbursement. This is why, when it comes to finding the costs of claim submission, only some claims consist of a cash receipt according to the policy plan.

–       How to find the policy coverage for certain treatments?

When you want to know the list of treatments and procedures that your policy covers, contacting your policyholder will help you go through every aspect of your plan’s medical coverage. The representative at your insurance company will provide the details of medicines and treatment that your insurance policy covers.

–       What are the main sources to get insurance information for a patient?

The person that can provide patient insurance information is the health insurance agent. He or she is a licensed professional who understands the coverage plans and the coverage that is being presented.

–       What kind of death insurance is not covered under an insurance policy?

When the deceased is involved in fraudulent activities, takes part in criminal or illegal activities, or death is occurred due to the higher amount of drug intoxication and accidental deaths is not covered by many insurance policies.

–       What is EHR?

Digital visualization of the patient chart is referred to as an electronic health records system. It holds patient records and medical history, making information available quickly to authorized users.

–       How quickly should providers submit the medical claims?

Providers should submit their medical claims as soon as they are prepared and approved by the medical billers and auditors. It is said that he claims must be started compiling within the 24 hours when patients leave the clinic.

–       What is the maximum time for submitting medical claims?

The maximum time for submitting claims for reimbursement is 45-90 days. Depending on the severity of the claim, the billing process may take several days to weeks.

–       What happens when medical claims are not submitted timely?

If the claims are not submitted timely, there may be process delays, and there would be a greater possibility of lost documents and upgrade in the claim submission process or any change in the patient’s insurance policy. If the claim submission gets delayed, the final settlement gets delayed.

Ending Notes

In order to give patients access to a wider range of accessible methods of payment, a range of healthcare organizations are considering making partnerships with a number of other financial organizations. If, for example, an end user decides to pay with a debit or credit card that any bank or financial institution issues, the medical professional receives the reimbursement within two business days, which ultimately smoothens the revenue management process and medical reimbursements. In addition, healthcare professionals will not be subjected to any legal repercussions if the patient fails to submit the payment as pledged. Patients have the ability to get the type of medical care that most accurately meet their needs according to their policy plans.