Understanding the Basics of Insurance Credentialing Services

Almost without exception, those in medical professions need to be able to accept insurance. And, at the same time, most medical professionals are not experts on the insurance industry! When a practice tries to save money by handling their own billing and insurance credentialing services, they can often end up frustrated, while at the same time missing out on revenue in a variety of ways.

Let’s go over a few of the basics of insurance credentialing—also known as “provider enrollment”—so you can get a sense of what’s expected throughout the process.

Two Main Steps: Credentialing and Contracting

You can think of credentialing as the “verification” phase of the enrollment process, while contracting is about setting the terms by which the insurance company will remit payment to you.

Credentialing

Credentialing requires you to send proof of your medical expertise to the insurance company, which they will then double-check and verify. They need to make sure that the patients in their network are seeing a bona fide doctor, so every healthcare provider must be carefully vetted to ensure they have attended medical school, passed their licensing examinations, and have a good track record of quality care throughout their career.

Different insurance companies have different application processes. Some companies have their own independent credentialing department, to which you must individually submit all of your materials. Others make use of CAQH (The Council for Affordable Quality Healthcare), which aims to streamline healthcare administrative practices by—among other things—consolidating credential information. Still others employ a state-standardized credentialing application. You cannot choose how to submit your credentials to any insurance company, but must use the process that they demand.

This thorough process takes around 90 days. All your submitted credentials must be perfectly correct, otherwise the process can take even longer if you have to correct mistakes or start over again. It is also wise to call in periodically to make sure that the company is actually working through the process of verifying your credentials, otherwise your application might sit even longer with no action!

Contracting

Once the credentialing committee at the insurance company approves your application, another department in the company will draw up a contract for your enrollment in their network. Many providers fail to realize that these contracts are negotiable, and you are under no obligation to accept a first offer if it does not meet your expectations. There is a great deal of fine print, some of which may allow the insurance company to change their reimbursement rates at any time! These clauses should be negotiated out of the contract, in addition to bringing reimbursement rates more in line with your expectations.

Once you have arrived at an agreement and signed a contract, you’ll be assigned an “effective date,” which is the first day on which you can begin billing the insurance company as an “in-network” provider. The contracting process typically takes somewhere between 30–45 days and, again, it is worth checking in to make sure the company is moving forward on your contract.

What Can Go Wrong?

The answer to this question is: quite a lot. Firstly, credentialing is not a one-time process, but something the company will expect you to update on a regular basis. If you fail to re-credential on their expected timeline, you can end up with significant financial losses, delays in payment, fines and penalties, and you may be removed from the network and need to do the whole process over again.

Any mistakes or incongruencies in your submitted credentials will significantly delay the process, or result in the need to start over again. Since you can’t bill as an “in-network” provider until you are contracted, delaying the process can be a costly mistake.

What’s more, it takes careful consideration to determine which companies you ought to credential with in the first place. What insurance companies are most common in your area, or do more of your potential patients rely on Medicaid or Medicare? If you end up contracted with insurance companies that don’t cover any patients in your area, it won’t have been of much use to you!

Finally, insurance companies’ contract language is always different between organizations, and intentionally arcane. It can be hard to recognize whether you’re being treated fairly until you analyze your revenue cycle and see which insurance companies tend to be reimbursing you at better rates. An offer might appear favorable, until you read the fine print and find out that what was in the larger print is a rare case, and most of your services will be reimbursed at a lower rate than the contract led you to believe.

For these reasons and more, it’s important to employ the services of a medical billing company that knows the insurance industry inside and out, and has expertise in your area of speciality. Healthcare Revenue Group was started by former providers with years of experience in general practice, as well as audiology and podiatry. We’ll set up systems for your practice that make billing streamlined, and we’ll ensure laser-accurate credentialing and contract negotiation with the right insurance providers in your area. Contact us today to find out how we can help you grow your practice at the pace that’s comfortable for you!