Insurance Credentialing For New Health Care Practices

Opening a new health care practice takes time, patience, money, and perseverance.  Like starting any new business there are hundreds of tasks that need completing to get ready to open your doors.  Healthcare businesses, however, have their own set of unique tasks that place additional burden on the practitioner.

In a health care practice, you have to make sure that your “customers” can pay for your services.  In a health care practice, your customers will hand you a plastic card to pay for your services.  It’s not a credit card that I’m referring to (although you will see those to), but an insurance card.  And the burden is on YOU to make sure that plastic card is good, covers your services, and the company behind that card will pay your claim.  How do you make sure your claim will be paid?  The simple answer is “Credentialing”.

Call it what you will; credentialing, provider enrollment, payer contracting, managed care contracting, insurance credentialing; it all refers to the same thing.  It all refers to applying to insurance carriers to be an “In-Network or Participating” provider.  Participating providers can bill insurance companies and receive payment as an “in-network” provider.  Which usually means your claims are paid timely and at a previously agreed upon rate.

Who should I participate with?

That is a question that is unique to your area.  Sure, there are the big national firms that you will need to enroll with such as BCBS, Aetna, UHC, Cigna, Humana; and the important government programs like Medicare, Tricare, and your state Medicaid program.  But there are also undoubtedly some unique regional players that may be important to you.

Identify large employers in your area and find out what networks they use.  Some companies may be self insured and utilize a third party administrator to pay their claims.  In which case they lease a PPO network of physicians from a national company or they may have their own network.  It can get confusing real quick when you try to track down these type of important networks.

If you have peers in the same market, ask their business manager who the important payers are in your area.  The hospital at which you have privileges could also assist you identifying those payers, so ask their billing managers.

And of course realize that who you need to participate with can change over time.  If you notice that a particular payer is insuring many new patients and your claims aren’t being paid, investigate enrollment with them.  It’s an ongoing process that is an important part of managing the business side of your practice.

When do I start the credentialing?

Start the insurance credentialing process early.  You can be limited to what you are able to do until you have office space, business bank account, and business organization together; but plan ahead for the credentialing process.  Have all your background documents, licenses, CV, insurance, and copies of all relevant documents organized and easily accessible.  Be certain to have a CV that shows your entire background from the time you graduated medical school to the present time.  And that CV must have month and year for each education, training, and work history entry.  A realistic time frame to becoming in network with 8-12 carriers in your market is 6 – 9 months.

Each carrier will have their own process, but basically everyone does the same thing.  First, you go through “credentialing”.  Which means they verify your education, training, work history, license, hospital privileges, references, and other background items.  When all the primary source verification is complete, your file is reviewed by the “Credentialing Committee”.  Expect a period of 90 – 120 days for this process.

If you are approved by the credentialing committee, then you move to the second step which is “Contracting”.  Contracting is the point that you receive a provider agreement to execute.  You can review the contract and attempt to negotiate favorable language and reimbursement before signing.  When you sign and submit your contract, the carrier representative does the same and then sends you a “Welcome to the network” letter.  Expect this process to take 30 – 60 days.

Considering the amount of time it takes carriers to go through the process, you can see why it is so important to start early.  Don’t wait a month before you want to open and expect that all your credentialing can be done with a phone call.  And don’t be under the mistaken impression that you can back bill insurance companies once your contracts are in place.  Other than Medicare allowing a period of 30 days prior to the effective date, you won’t be able to retroactively bill for your services and collect “in network” rates.

Until you are in-network with carriers, your claims will be processed as out of network.  Which means you won’t receive much reimbursement directly from the insurance company, if you receive any at all.  Some plans pay the patient directly for out of network claims, so you’ll have to collect that from your patient.  Until you are in network, the best bet would be to collect for your services from the patient at time of service and give them a claim for to submit to their insurance company.  If you plan to participate with a patients insurance, you may want to “match benefits” for the patient and only charge them what they would have paid if you were in network.  This means getting only a fraction of payment, but once your contracting process is complete you’ll have a better chance of having retained that patient and be able to treat them in the future.

How do I start the credentialing process?

Once you’ve identified your target networks, you need to call their provider services department and ask whether or not their network is open in your area for your specialty and what their process is to become a participating provider.  Some carriers have online applications, others will send you paper forms to fill out.  The enrollment process will be lengthy and time consuming so be prepared.  If a network is not open in your area, you can ask for a time frame to check back to see if it is open.

Along with your insurance credentialing application you’ll need to submit supporting documents.  Here is a summary list of documents that you need to have handy and accessible to submit with various applications.

When you submit your application and documents, there are three steps that are critically important.  1) Follow up on your application submission to make sure it is received and in process, 2) Follow up on your application submission to make sure it is received and in process, and 3) Follow up on your application submission to make sure it is received and in process.  It’s not uncommon for your request to participate to be lost.  Whether your email is routed wrong, your fax did not transmit, your fax went to the wrong person, or your mail was lost.  These things occur so you better be prepared and ready to re-submit that application.

Follow up with the carrier every 15 – 30 days to make sure things are progressing and to find out if anything further is needed to complete your file.  There is nothing that you can do to speed up the process, but your continued follow up will ensure you know if the process has stopped for some reason.  You’ll receive notice when your application is complete typically by letter, email, or fax.

Again, expect the entire process to take anywhere from 60 – 180 days for EACH carrier to complete the entire credentialing and contracting process.  That time frame is from the time they receive your complete application with all necessary documents.  So start early!

Some helpful hints:

Hire professional assistance.  There are many different organizations that can help with the insurance credentialing process.  If you’ve contracted with a practice management company this process is often covered in your services. If you’re utilizing a a medical billing company they may take care of the enrollment process for you as well, or have advice on how to manage the process.  nCred can provide you with a complete provider enrollment solution to make the credentialing and contracting process go smoothly and efficiently as possible.  Give us a call today to discuss a service plan to meet your needs, or complete our online form for more information.

Summary

The insurance credentialing process is critical to getting your practice off to a good start and ensuring positive cash flow early. While it can be time consuming, an early start will give you the chance to complete the process and identify problems early.  Just be patient and keep these tips in mind as you go through the process.  Remember, START EARLY and expect the process to take 6 months or more to get enrolled with all the carriers that are important to your practice.

 

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