Time and again new practices invest countless hours and money focused on office space, equipment, software and staffing only to open their doors for business and find significant delays in getting adequate insurance reimbursements. More often than not, the problem could have been allayed by addressing the insurance credentialing process early and thoroughly creating the necessary relationships with insurance carriers. Here are a few considerations to keep in mind as you address the insurance credentialing process. Remember to download our practice start-up checklist available in our resource center. This should help to shed some light on some areas that you may not have thought about.
Timing Start Early!
Plan on starting the insurance credentialing process early – at minimum allow at least four months before you see your first patient. Carriers will often take as much as 3-4 months to review documents and make a determination, even if everything is in order. If there are errors, missing information or a question about submitted documentation, several more weeks or even months can be added to the process. This six month allowance, starting from the time credentials are submitted, usually gives enough time to address problems should they arise. If too little time is granted before the practice opens, and you begin seeing patients before insurance credentialing is complete, you are open to the risk of getting an out of network rate, reimbursements might be sent to the patient, or, worst case scenario, you may not get paid at all.
Utilizing Physician Practice Specialists reduces the average time for Medicare & Insurance enrollment by 2-4 months.
Identify Target Carriers
To define which insurances you might credential with, consider your practice location and patient demographics. Will a significant percentage have Medicare or Medicaid? Is there a particular company or business in the area that employs a large portion of the surrounding population? A quick call to their human resources office to inquire what insurances they currently offer employees (as well as possible changes the near future) can be a good indicator of the carriers you will want to consider.
Physician Practice Specialists conducts the research necessary to credential you with the insurance companies that are applicable for your area. We will also add any additional insurance companies during the first year of your practice through our maintenance agreement.
**Remember that carriers wont start the insurance credentialing process until you’ve established a practice phone number and address (a PO Boxes are not acceptable). If you’ve established a practice address but haven’t moved in yet, carriers can usually send the forms to an alternate address, but you’ll still have to identify the location to get things going.
Submitting Credentials
Each insurance company has their own unique credentialing process but many of them now utilize the application produced by CAQH. Depending on your state and specialty they may also require the state credentialing applications. The Louisiana and Texas standardized credentialing applications are examples of this.
Once you’ve completed the application, don’t forget to double check everything. In fact triple check it and have someone else look over it as well. Don’t expect carriers to correct an obvious mistake for you its not their responsibility, and, frankly, they just wont. The importance of double and triple checking cannot be stressed enough as the entire process can be help up by a month or more from the slightest mistake. Medicare is a great example of how critical it is to ensure a corrected form is submitted. If you submit an application with an error on it then they will just return it to you and further delay you participating with them. Click here for more information on Medicare Enrollment. If you would like assistance you can simply follow the links on Medicare Enrollment page or visit this page and follow the three simple steps.
Finally, after your information has been submitted, allow an appropriate amount of time (1-2 weeks for mailed submissions) and follow up with the provider services office to confirm receipt. If you were able to obtain a contact name in your early research call them directly. Once receipt is confirmed don’t hesitate to follow up again in say, 3-4 weeks to see if they’ve reviewed it yet or if they found any problems. If everything is on track, plan on checking back in another 3-4 weeks until the process is complete. This can save a lot of turnaround time if you can learn over the phone there was some sort of hold up. As alluded to above, expect this part of the process to take several months credentialing offices are often centralized and may be reviewing hundreds of submissions for many different areas at any given time. If there’s no movement after several months, you consider stepping up your calls to a weekly basis.
Hopefully your hard work and phone calls has paid off and you’ve made it through the insurance credentialing process in just a few short months with your original list of 7 or 8 carriers. If you’re up for the challenge yet again, consider going back to your longer list of 10-15 and start the process all over again with the remaining carriers.
A few shortcuts
Here are a couple of shortcuts to credentialing not mentioned above.
Hire professional assistance: There are many different organizations that can help with the insurance credentialing process. By using a professional service you can typically cut the credentialing process for most major carriers in half. The primary reason for this is the fact that a professional organization will have relationships with the primary contacts at all of the insurance companies. They also are intimately familiar with the process which ameliorates potential delays.
Universal Credentialing DataSource: The Council for Affordable Quality Health care has developed an online service intended to eliminate the need for multiple insurance credentialing submissions. You first must obtain a CAQH ID which you can do by visiting CAQHCredentialing.com. In short, CAQH is an online repository which allows you to store your information and insurance companies access to it. The CAQH Universal Credentialing DataSource is located at: http://www.caqh.org/.
When forming your corporation, it is recommended to use a service like LegalZoom or have an attorney set it up for you. Delays and errors in setting up your organization can delay the rest of start up process. Remember to keep your CP-575A (IRS EIN Formal Letter) in arms reach as Medicare will need this to verify your entity. Also, make sure your business bank account and business checks match the IRS Letter identically.
Summary
The insurance credentialing process is critical to getting your practice off to a good start and ensuring a quicker transition to profitability. While it can be time consuming, an early start will give you the chance to address problems should they arise. Just be patient and keep these tips in mind and you’ll get through it:
