All About Insurance Credentialing

All About Insurance Credentialing

Practitioners of all kinds must be credentialed in order to receive insurance reimbursements. Those who do not credential with multiple insurance networks are limiting the possibilities for their practice, perhaps significantly. The more provider networks you credential with, the larger the percentage of patients who you can treat.

Credentialing History

Credentialing has been around nearly as long as humans have been attempting to cure one another’s ailments. The earliest mention in the history books is from ancient Persia, in 1000 BCE. A physician was required to treat three convicted heretics to demonstrate their skills. If the heretics survived after treatment, then the physician could go on to practice medicine in the kingdom for the rest of their life.

Today’s credentialing process is much less brutal, though if you’ve spoken to other practitioners who have gone through the process, you might be tempted to think otherwise! The whole process can take anywhere from 90–120 days, and small mistakes can require you to start all over again. And that means lost revenue until you receive your effective date. While the Medicare program allows you to “backdate” your credentialing to the time when you submitted your application, this is not the case with most private insurance networks. You’ll have to wait until you have completed the credentialing process, signed a contract, and received an effective date when billing can begin.

The Credentialing Process

Different states and even municipalities have different rules regarding the credentialing process. And, of course, federal programs like Medicare and Medicaid have their own sets of rules, as well. You’ll need to take care to follow exactly the process laid out by each entity with which you intend to credential, according to the specific laws in your state and/or municipality.

Information Submitted

Credentialing requires you to provide information about your training and experience. You’ll need to submit information regarding:

  • Education and training
  • Residency
  • License
  • Specialty certificates
  • Work experience
  • Additional qualifications

Committee Verification

All of this information will be thoroughly verified by the insurance network. If they are unable to verify something, it can be a significant setback to completing the process and may even require you to start over again. So you want to be sure you get everything right the first time! Information must be approved by a Credentialing Committee, and when they sign off the second part of the process can begin.

Contracting

The second part of the process is called “contracting.” This phase can involve negotiating, especially if the network’s reimbursement rates are lower than you expect. There will be some responsibilities of participation outlined in your contract, as well. This can be a nerve-wracking part of the process, as you need to make sure you’re engaging with a network that will recognize your worth appropriately. Once the contract is signed and returned, you will be given an effective date of membership, on which you can begin billing them, receiving “in-network” reimbursement. This phase can add an additional 30–45 days to the process, after credentialing is completed.

Periodic Re-Credentialing

Every so often, a network will require you to go through the process again. You should receive a letter from the network alerting you to the need to re-credential. The letter will indicate a deadline, after which your contract may be suspended if you have not re-credentialed by that time.

Federal Program Credentialing

For Medicare, Medicaid, Tricare and other government programs, you receive standard forms that you can fill out. These are returned to a local intermediary, where they are reviewed against strict standards for enrollment. Check the Centers for Medicare & Medicaid Services (CMS) website for details regarding these standards.

How to Credential Effectively

Larger group practices often provide a credentialing packet to staff that allows them to complete the process more easily. If you are preparing such a packet, it should include:

  • Practice name and address of remittance
  • Phone and fax numbers
  • TIN
  • National provider information
  • W9
  • Instructions for CAQH (Council for Affordable Quality Healthcare) and NPI (National Provider Identifier) applications
  • A list of the networks / companies they need to apply with

However, credentialing can be such a time-consuming enterprise, rife with possibilities for costly errors, that many practitioners choose to outsource this work. This allows you to do what you do best, while a group with expertise in credentialing handles that side of things for you. Healthcare Revenue Group has expertise in medical credentialing, as well as special knowledge regarding credentialing for audiology and hearing care practices.

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