Tips for Successful, Timely Provider Credentialing

Lessen frustration during the insurance credentialing process.

By Olga Khabinskay

Payer networks, healthcare organizations, and hospitals require credentialing to accept a provider in a network or to treat patients at a hospital or medical facility. The seemingly straightforward credentialing process is fraught with complications that can frustrate even the most patient practitioner. The good news is there are ways to save time, aggravation, and rejection during the process. But first, it’s important to know the purpose of credentialing.

Why Get Credentialed?

Credentialing involves obtaining and evaluating documentation regarding a medical provider’s education, training, work history, license, regulatory compliance record, and malpractice history. If a doctor is not “credentialed” by the insurance company, Medicare, or Medicaid plan, he or she can still submit claims, but the doctor may not be paid unless the patient has out-of-network benefits.

Begin the Paperwork

The process starts with the credentialing form—some 20-40 pages, on average. Most insurers require a license, hospital affiliation, and malpractice insurance. They also may use much of the information that can be compiled in the Council for Affordable Quality Healthcare (CAQH) profile, which is a database on every practitioner. CAQH is a non-profit alliance of health plans and trade associations working to simplify healthcare administration through industry collaboration on public-private initiatives.

A completed CAQH profile puts practitioners a step ahead in the process, particularly in getting on Medicaid insurance panels.

Choose Your Location

Panels are open or closed to practitioners, depending on where they will practice. When a doctor decides to join a practice, he knows which insurances the practice takes already, but that doesn’t mean the insurers will accept additional practitioners. At the start, this can be an important element in deciding which panels to join.

If the office can’t help, a reputable credentialing company can tell you with a phone call whether panels are closed to a specialty. That saves time in applying, only to be rejected weeks or months later.

Open Closed Doors 

Too often, panels are closed, especially in cities where numerous doctors of the same specialty practicing within blocks of one another may request credentialing. But there are ways around these rejections.

When doctors close an office or retire, they often forget to inform insurers of their inactive status, which prevents another doctor from taking over that spot in the network. The insurance company isn’t likely to know, and isn’t likely to tell you. This can only be challenged by a phone call to the practice or a site visit to see if it is still in business.

Differentiating your practice is key. Describing detailed specifics, such as all certifications, specialized equipment being used in the practice, specific experience, and even awards could set the doctor apart and open up a panel spot.

How Many Is Too Many?

Can a practice thrive taking on Medicare, Medicaid, and five other insurances? Do they need more?

The answer is, “It depends.”

It’s incredibly time consuming for someone in an office to submit applications for more than a dozen insurances. At the start, due to costs, it’s practical to be on five to 10 insurance panels, although there are as many as 60 insurance plans. You may wish to apply to several additional panels, in case the doctor is not immediately accepted to the most-favored plans.

Be (or Hire) an Advocate for Your Approval

It would be great if sending in the form, waiting a few weeks, and being approved were the reality.

The reality is that the credentialing process requires you to shepherd your paperwork through, answer questions and provide additional information, and ensure everything is correct and has been received. Otherwise, you’re likely to be rejected.

Here are a few tips on how to prevent this from happening:

Communication is key! Establish a friendly rapport with the provider relationship representative at the insurance company who is handling your case. Find out all of his or her contact information at the outset, and communicate in a clear and effective way (as often as once a day) to answer related questions and follow up on processing applications.

Ensure accurate information. Remember the three C’s: Correct, Complete, and Concise. All three will result in a smoother processing of your application. Make sure all information is submitted at the same time according to a checklist (which is usually provided with the application). Ensure the documentation is mailed with a tracking number. Verify the information was received.

Manage the process. Keep dates on your calendar for tracking and follow up. This will lead to faster processing. Set reminders for yourself to call and verify the status of your application on a regular basis by phone and email.

If this all sounds like a lot to manage (and dealing with five to 10 insurance panels can, in itself, become a full time job), that’s why there are services that can help.

Consider a Service to Lessen Aggravation

A reputable credentialing service—which often also offers medical billing and insurance auditing services, etc.—can shave weeks off an approval by making sure the form is filled out correctly the first time, keeping it on track, and providing requested information. A credentialing service’s established insurance company contacts, and their ability to determine the appropriate insurances ahead of time, will save a lot of aggravation and rejection.

Most credentialing companies will charge approximately $400-$600 per insurance application. That may sound like a lot, but it’s a wise investment that enables practitioners to start billing and making money sooner. With earlier acceptance to an insurance panel, the reimbursement from only three patients will cover the cost. Balance the cost of weeks of approval delays verses how many patients can be seen and billed and that amount suddenly seems negligible.

 

Olga Khabinskay is chief operating officer of WCH Service Bureau (www.wchsb.com), a global provider of healthcare practice services offering an array of billing and healthcare management services for large and small medical groups and practitioners. WCH provides medical billing, credentialing, coding, chart auditing, and customized medical software solutions, as well as receptionist services and Continuing Education Unit (CEU) credits. She is a member of the Jamaica, N.Y., local chapter.

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