Credentialing Process for Optometry Practices



Getting credentialed with the right insurance panels is a key to growing your practice revenue. However, the credentialing process can be a daunting task.  Are you aware that a Medicare application is a minimum of 30 pages for a solo provider and may surpass 50+ pages if you are a corporation or group practice? Even a single mistake in the credentialing application process may delay your acceptance and affect your cash flow. Hence, you have to understand how to do it correctly or find someone who can do it for you, like outsourcing the credentialing process so as to keep the cash flow going and maintain a healthy Revenue Cycle Management (RCM) process.

Optometry, part of the highly specialized medical community, although historically had never acknowledged the credentialing process, has of the recent past, found the need to employ the credentialing process,  in line with other third party payers, so as to provide proper patient care and management. It was only after 2010, that the credentialing committees at the Joint Commission (JC) accredited facilities began credentialing optometrists certified by ABCMO as specialists in medical optometry. Moreover, with the new payment models that have been introduced along with Value Performance Fee system, and the referral system, credentialing of your optometry practice is a must. If at any time you are required to apply to a JC accredited medical Facility, then you will need to be credentialed.  Credentialed Optometrists are now part of the Medicare Physicians by the Centers for Medicare and Medicaid for billing and other purposes. Approximately 85 percent of US medical facilities are accredited by the Joint Commission and its accreditation is the “gold standard” and a prerequisite for Medicare-Medicaid participation and billing.

Although the credentialing process for optometry is very complicated, here are some essentials that you need to be aware of if you do it yourself or if outsourcing to a third party vendor.

  • Type of Practice: You as an Optometrist need to choose the type of practice – solo, small independent group practice or large group,  part of a Managed Service Organization (MSO), as each has its own advantages and risks. So due diligence and meticulous planning is required as this could affect the Revenue Cycle Management of your practice, once you are credentialed under a certain Level
  • Specialty: When initiating Credentialing you need to determine whether you wish to be credentialed as a general practitioner, specialist or sub-specialist. When seeking appointment at a JC accredited health facility, an ABCMO certified optometrist can be credentialed and privileged as a general practitioner of optometry or a specialist board certified in medical optometry
  • Place of Practice: Determining where you practice also makes a big difference to the way your optometrist practice will be coded and billed and make revenues. Obtaining hospital Privileges has its advantages.  Given the changing healthcare reforms, rules & regulations, and as under the Obamacare Act,  which has pulled in many more footfalls,  elderly patients  will need access to optometrists either in their offices, in long-term care facilities, at home, and, yes, even in hospitals. Hospitals will now play an important role in future health care delivery and optometrists must continue to seek and be granted hospital privileges and for this credentialing is a must.
  • Qualifications & Licenses: You will be screened for your professional training and identified for the range of optometric services you can deliver. During the credentialing process, optometrists are often asked to submit  information on education and professional background, current licensure to practice optometry, Drug Enforcement Agency license (if applicable) and applicable certificates to dispense controlled substances or therapeutic agents. All optometrists need to demonstrate a valid license with no pending quality of care complaints. This is verified with each respective State Board of Optometry or the AMA for MD’s and the National Practitioner Data Bank – along and lengthy process but has its long term benefits
  •  Re-Credentialing: Do note that the re-credentialing process occurs every three years. This entails evaluation of the provider’s performance, and includes any complaints on-going or adjudicated during the year. There are also re-verification of credentialing documents such as the professional license professional, liability insurance, DEA registration certificate, and other applicable documents. Respective State Boards of Optometry are queried concerning any adverse actions against the license of the provider.

Those optometrists who cannot demonstrate compliance with or adherence to the credentialing, performance and practice standards usually do not obtain the credential stamp. Optometrists can also find it difficult to be retained within a provider network without being credentialed. As an Optometrist, during the credentialing process you need to have adequate professional liability insurance & be free of any malpractice claims. Any of the above can affect your reimbursements affecting your RCM process. So to put together all the documentation and accreditation’s & licenses, if you wish to be part of the CMS billing and coding system, to enhance your revenue, credentialing your practice is very essential.

This entry was posted in Medical Billing, Optometry Billing, Revenue Cycle Management (RCM) and tagged , , , . Bookmark the permalink.


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