What's the Difference Between (Medical Billing and Credentialing)?

Posted by Lauren Lau on December 3rd, 2019

Medical Billing versus Credentialing

Medical billing and credentialing for medical providers are two different categories in the healthcare world. Before any medical billing can even be completed, the healthcare provider needs to be credentialed with insurance companies in order to be an approved provider of services. Becoming credentialed as an in-network provider dictates the set amount of reimbursement that provider can expect back.

After the credentialing process has been completed the healthcare provider is then able to start treating patients in that network and sending claims for reimbursement. A medical biller will use CPT and ICD-10 codes on the claim to describe to the insurance companies what treatment the provider has given. They will then follow up on the claim to make sure that it has been properly paid by the insurance company.

Medical Billing

In terms of medical billing, our experienced and professional staff is committed to your practice and we carefully analyze each claim before it is submitted to ensure a clean claim submission. Each claims is examined to see if it has the correct CPT code(s) associated with the diagnosis code(s), along with comprehensive insurance information and complete patient report. This reduces the chance of dismissal by an insurance company. By providing the highest percentage of clean claims, medical provider revenue increases are ensured, as well as the decrease in the amount of labor needed to follow-up on denials.

Credentialing

Credentialing services are essential to new medical practices. Medwave assesses the license, performance, credibility and background history of insurance companies to understand what needs to be initially generated. This includes ensuring that your practice is in-network with all of the insurance companies that serve your patients. This is a crucial part of any medical practice’s cash flow. We help negotiate the payment for services rendered, meeting agreement terms, and facilitating the payment processes. A plethora of medical professionals rely on us to provide them with the peace of mind that all credentialing processes are a go.

We ensure that payment rates are accurate. By managing the information for any practice or physician data on file, we minimize the likelihood of being underpaid for your services. By periodically following up with the physician to ensure that current payment rates are always up to date, the physician can be assured that their files with payers are correctly maintained.

Our credentialing services not only focus primarily on maintaining the service rates of providers, but we focus on the entire profile of the billing office. For example, a physician with a particularly hectic schedule or a practice with a more extensive client base may overlook specific details such as updating records when moving. We help make sure that the provider address information remains up to date. Additionally, we help ensure that all profile data on the practice is complete. Incomplete records for a practice can result in compliance issues later down the line. We help maintain complete profiles, which helps with matters of compliance.