By: Ray Jorgensen, Co-Founder, PMG Credentialing

A couple of weeks ago I overheard my wife talking to a doctor’s office about a bill. She was convinced a payment had been made by our health plan and we did not owe money. Without getting too detailed, we have a High Deductible Health Plan (HDHP) in the form of a Healthcare Savings Account (HSA) and it was too early in the deductible year for us to be near the deductible limit. Suffice to say I married out of my league… smarter, gorgeous, nicer, etc. She did not take kindly when I suggested that she did not understand the bill which in fact showed a “payment” in the form of Blue Cross Blue Shield reducing the charge down to the fee schedule negotiated with this doctor. It was not a payment BUT simply an “adjudicated” claim with the balance being owed by us. What was easy for me to grasp with twenty-five-plus years in healthcare billing and coding, was not so simple for my brilliant med-school-drop-out-award-winning-author-wife. Just that call (and subsequent conversation with me) was 45+ minutes of her life she will never get back.

My business partner sent me an article from Becker Hospital Review which said US residents collectively spend 12 million… TWELVE MILLION… hours a week conversing with payers. The aggregate of every “quick call” that took three to five minutes to answer after being on hold for 30 minutes adds up. I started my career as a customer service rep for UnitedHealth and Blue Cross Blue Shield. The phones NEVER stopped ringing. 

Make no mistake, the US healthcare system is wildly complex and the myriad of seemingly avoidable obstacles to claim payment is maddening. Like my near-Mensa-level bride, she could be exceptional at reading explanations of benefits (EOBs) and healthcare billing and coding, but it is just not in her wheelhouse. It is not what she does day in and day out. Unreasonably long calls with payers happen primarily because she is simply not skilled in the complex arena of healthcare coding, billing, and reimbursement.

Credentialing and enrollment to me is another example. Health center staff, who don’t do credentialing and enrollment every day simply cannot be as efficient as a person (or better yet a team of health center-centric persons) who engage with payers around credentialing and enrollment day in and day out. The credentialing and enrollment time-suck need not be so challenging. Yet, even the most capable staff person struggles with accurate applications, addendums, current licensure, certificates, primary source verification.

If unenrolled or uncredentialed providers are keeping you from optimizing reimbursement or fraudulently submitting claims under another provider’s number, stop the madness. Call PMG Credentialing or another firm that works, EVERY DAY, in healthcare credentialing and enrollment. You will be glad you did.