Credentialing 7/11/2018. Peter J. Cass, OD - Disclosures. Credentialing. Credentialing Purpose
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1 Peter J. Cass, OD Peter J. Cass, OD - Disclosures Owner, Beaumont Family Eye Care (VS) Beaumont Texas Vice President, Practice Compliance Solutions Immediate President, Texas Optometric Association Chair HIT Committee, AOA Health Information Exchange Workgroup Consultant/Speaker for ophthalmic companies: Alcon, Bausch & Lomb, Crystal Practice Managment, Diopsys, Solution Reach, Katena, Tear Science, Shire Lecturer for Professional groups: Vision Source, Vision West, ECPN, PERC, Vision Trends, Vision West, TSO, etc. Universities: RSO, UHCO, UAB, etc. State associations: TOA, and over 20 others Working relationships with: Clienman, CodeSafePlus Shareholder Essentia, EDO labs, OBS, PCS Required to be offered a contract from a payer I am credentialed on almost every medical panel in our area Medicare is typically the first panel to start with Other common ones include BCBS, United, Aetna, Humana, and Cigna Purpose The process by which an insurance company verifies that you are who you say you are. This includes checking state license, DEA, Fellowship, Malpractice insurance etc. 1
2 7/11/2018 Verification Methods Medicare & PECOS Each insurance company verifies credentials differently: Medicare prefer PECOS Most medical plans use in-house verification In Texas, can use the Texas Standardized Application Most vision plans accept CAQH Provider Enrollment, Chain, and Ownership System (PECOS) CMS preferred method for Medicare enrollment scenario-driven application Can submit supporting documents through PECOS Texas Standardized Application CAQH Allows for the Texas Insurance Commissioner to adopt a standardized form for verification of physician credentials. Use of the application form by hospitals, HMOs and PPOs is required for credentialing of physicians. The credentialing form is based on CAQH Register with CAQH a centralized application process Used by many vision insurances companies No need to reenter the data for each plan 2
3 Prerequisites Optometry License NPI Number Liability insurance Process There are three parts to the process Applying Contracting Steps 2 & 3 are often done at the same time What You ll Need to Get Started CAQH-supplied Provider ID Number Previously completed credentialing application if available (for reference) List of all previous and current practice locations Identification numbers, such as Social Security Number, National Provider Identifier (NPI), DEA, UPIN, and License Number You Will Also Need Electronic (scanned) copies of your: Curriculum Vitae Optometry License DEA Certificate CDS Certificate IRS Form W-9 Malpractice Insurance Face Sheet (Summary of any pending or settled malpractice cases) Any other required supporting documents 3
4 Considerations Type of Practice solo, small independent group practice or large group Specialty determine whether you wish to be credentialed as a general practitioner, specialist, or sub-specialist. Place of Practice will affect they way you code and bill Qualifications & Licenses will affect the range of optometric services you can deliver Re-verification Re-verification required periodically, usually requires resubmitting: Professional license Professional liability insurance, DEA registration certificate, and other applicable documents. State Boards of Optometry review for any adverse actions against the license of the provider So 2 options 1. Do it yourself 2. Hire it out is not rocket science. Doing it yourself simply requires diligence Do it Yourself 1. Fill out all forms and submit 2. Wait two weeks if you are not confirmed, start calling every Monday morning for progress update until you are DIY 4
5 Hire it out If you decide to hire it out understand 3 things: 1. YOU still have to put all the necessary forms together 2. YOU still have to provide the credential company with ALL the information they need 3. The ONLY things you are paying them for: licking the stamps or pushing send and follow up calls average charge usually $ per company (sometimes even per doctor in the practice) 5
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