New practices spend countless hours and large amounts of money on staffing, equipment and software, only to open doors and face delays in receiving adequate insurance reimbursements. The problem can be solved by properly and early addressing the insurance credentialing process – establishing the necessary relationships with the insurance carriers. These are some things to remember when you tackle the insurance credentialing issue.
Timing: Start Early!
Start the process of insurance credentialing early. At minimum, allow six months to see your first patient. Even if all documentation is correct, it can take up to 3-4 months for carriers to review and make a decision. There may be errors, missing information, or questions about the submitted documentation that could take several weeks, or even months, to review. The six-month allowance that begins from the date credentials are submitted usually allows enough time for problems to be addressed. If you allow too much time before your practice opens and begin seeing patients before you have insurance credentialing complete, you could be charged an “out-of-network” rate. In this case, reimbursements may not be sent to the patient or you might not get paid at all.
Identify Target Carriers
Consider your patient demographics and where you practice to determine which insurances you may be able to credential with. Do you have Medicare or Medicaid? Are there any businesses or companies in the area that employ a significant portion of the local population? It’s worth calling their human resources department to find out what insurances they offer current employees and any changes in the near future.
Ask your colleagues, other providers, and clinics in the area for their most frequent payors. Ask about the best payers to work with, who is responsive, who offers the highest enrollments, and what carriers may be available with other providers in your field.
Make a list of top 10 or 15 insurance companies in your area. Next, consider what other providers have to say about the area and narrow down that list to 7 or 8. This will give you a short list of places to go. Do not choose too many – you will be overwhelmed by the number of submissions.
Contact Insurance Carriers
Prepare to spend at most an hour on the phone with each provider service office of your target carriers, starting with your 7 or 8-person list.
Asking if they accept new practices in your field of specialty might be one of your first questions. Most of the time, there is no problem. However, don’t get discouraged if they refuse to answer your question. Keep moving down the list and be prepared to call them again later to inquire about openings. You might consider reassessing your location if multiple carriers indicate that they are not open to new providers. Multiple carriers in the same area could be a sign of a lot more competition.
If your carrier is open to you becoming a new provider, ensure that you have all the relevant information. Names, addresses, phone numbers and required forms. Ask about online submission, as many carriers allow you to submit all your information online and then mail the supporting documentation.
Remember that insurance carriers will not begin the process of insurance credentialing until you have established a practice telephone number and an address. PO Boxes are unacceptable. Carriers can send forms to another address if you have a practice address established but not moved in yet.
Submitting Credentials
Once you have done your research and determined which insurance companies you want to file with, it is time to compile all your information and submit it. Generally, most insurance companies will require that you provide the following information:Resume updatedDemographic informationInformation for business and practiceNumbers for federal and state DEA officesInformation about state licensing and registrationDocumentation proving education, i.e. Certificate of ECFMG or diplomaInformation about Malpractice InsuranceInformation about any disciplinary actions
This can be quite overwhelming, but there are some good things. Since most carriers require the same information, once you have submitted the first submission, you can simply transcribe the details from the next form. It will be a huge benefit to keep copies of these documents safe. This will allow you to access the same information as you do with your other insurances when your practice grows and you apply for credentialing.
After you have submitted the application, double-check everything. Double-check it, and ask another person to look at it. Do not expect carriers to fix an obvious error for you. It’s not their responsibility and they won’t. It is important to double- and triple check as this can make the whole process take up to a month.
After your information has been submitted, please allow a reasonable amount of time (1-2 week for mailed submissions), and then follow up with provider services to confirm receipt. You can contact the provider services office if you were able find a contact person in your initial research. After receipt has been confirmed, don’t hesitate in following up with them again in 3-4 weeks to verify if the item was received and if there were any issues. Once everything is in order, you can check back in 3-4 weeks to make sure the process is completed. If you are able to find out by phone if there is a hold-up, this can help save time and reduce turnaround times. This part of the process can take many months. Credentialing offices often have hundreds of submissions and may need to review them all at once. You might consider increasing your calls to the weekly level if there is still no movement after several months.
You’ve probably made it this far with just a few months of hard work and phone calls. You might consider returning to your longer list, which includes 10-15 carriers, and re-starting the process with those remaining.
Some shortcuts
These are some shortcuts for credentialing that have not been mentioned.
Get professional assistance: Many organizations can assist with insurance credentialing. This process is usually covered if you have a contract with a practice management firm. A medical billing company that manages your patient billing and insurance should have experience working with carriers. There are also a few insurance credentialing firms that specialize in new practices, but these can be expensive.
Universal Credentialing dataSource: Council for Affordable Quality Healthcare developed an online service that eliminates the need for multiple insurance credentialing submissions. You simply complete one form to be able to submit your information to all participating insurance carriers.
Summary
It is crucial to get your practice off the ground quickly and to be able to credential insurance. Although it is time-consuming, it will allow you to identify potential problems and address them quickly. These tips will help you get through the process:It is best to start early. The process can take up to 6 month.Pick a target list. Don’t try to be everywhere.Before you send your work in, double-check itKeep the process moving by following up on it regularlyDo not be overwhelmed by the paperwork.