What to know about insurance credentialing when starting your own practice

What is credentialing in healthcare, and how can it help your practice? This article will cover:

Obtaining credentials from insurance companies will allow you to accept more and a wider variety of patients. You will be better able to help your community. You’ll also be better able to grow your revenue.

Being credentialed is not the same as being licensed. In the United States, a medical license indicates that you have:

However, being credentialed with various companies and agencies allows you to get reimbursed via claims you submit for a variety of procedures you offer. Insurance companies, including Medicare, require additional verification of your information, including information about malpractice claims, to officially deem you a safe and trusted provider for their members. 

Before we dig into the process, let’s discuss how you determine who within your practice needs to be credentialed.

Credentialing requirements vary by state. Therefore, check your state’s medical board website to verify who on your staff must go through the credentialing process.

At this point, apply for or update your national provider identifier (NPI), if you haven’t already. This is a unique 10-digit designation that each healthcare provider uses to identify themselves in their standard treatment documentation and transactions.

Not all insurance companies or plans are standard in every area. With that in mind, determine which insurance programs your patients will likely expect you to accept. In addition to major national carriers such as Aetna, Blue Cross/Blue Shield, Cigna, Humana, and United Healthcare, consider any common regional insurance carriers, along with Medicare and state-based programs like Medicaid. One way to go about this is market research — you can call or visit the websites of your competitors to see which insurances with whom they work.

Once you have compiled this list, call each insurance company to determine which panels are and aren’t open to new practitioners at the current time. For those currently closed to new applicants, find out when they anticipate accepting new credentialing applications.

The credentialing process takes time to complete, so ensure you have your basic facts together before you start the official process.

Now that you’ve identified which insurance boards to approach for credentialing and which currently accept new practitioners, complete a pre-application for each. This part of the process allows the insurance carriers to conduct a semblance of a background check to ensure that you have the basic qualifications to enable you to practice medicine.

Once you’ve submitted your pre-application to each company, it’s time to gather all of the pertinent information.

You will need to provide the following:

Group credentialing is available when you are joining or starting a larger practice. The initial application process is similar to what happens when an individual provider or a practice with just a few physicians apply for credentialing. However, the ongoing process focuses only on the individual new provider information because the physical practice information doesn’t change.

Send this information as one cohesive packet. If you send it piecemeal, portions will likely be misplaced or attached to the wrong file. To help you organize your data, consult the following  checklist you can use to ensure you have gathered everything you need.

The insurer may use a third-party company called a credentials verification organization (CVO) to gather and parse through all of your documentation. Most will accept your information via email, electronic document transmission, or snail mail.

In some cases, the CVO may do a lot of the background searches to gather various pieces of your packet. For it to do this, you will likely need to sign an affidavit allowing it to access your personal information.

Regardless of whether you work with a CVO or a company representative, get a contact name, direct phone number, and email address when possible.

Once the insurance company approves you for credentialing, you will enter the contract phase. During this process, you contract with the insurance company outlining which in-network services you will provide, the percentage of your fee they will reimburse, and how you will receive reimbursement from them.

The contract will also define which party is responsible for instances that involve multiple insurance companies. The coordination of benefit-filing responsibilities often initially falls on the practice, then shifts to the insurance companies as they determine which company pays what percentage of the treatment bill.

There are 3 potential challenges that might arise during your credentialing process.

First, not all insurance providers within an area are open to additional medical professionals. In some instances, the insurance company’s market research may indicate the market is at a saturation point regarding its services. If this happens, ask the representative if they know when that decision may change.

Additionally, share any information you have that the insurance company doesn’t, such as if you are taking over an existing practice and will acquire an established patient base that is accustomed to having their insurance accepted. This may influence a different decision.

Second, some companies require experience before contracting with a new physician. This doesn’t apply to all companies and is less frequent than it used to be. Still, some indicate they want a medical professional to have anywhere from 6 months to 2 years of experience before they will include that individual in the credential process.

Third, not planning enough time to complete the process. Multiple websites and agencies suggest you need to plan 6 to 10 hours to gather your information to simply begin the credentialing process. Once you submit your packet to each insurance company, you will have to schedule time to follow up with those organizations, gather additional information they request, and keep your application process moving forward.

Know that just because these are potential challenges, it is not a given that you’ll run into them.

The length of the process varies depending on the company or agency with whom you’re working. In general, you can estimate the approval time:

If you plan to practice before you receive your official credentials, you can request a statement of supervision. This will allow you to temporarily bill under a supervising physician until your credentialing process is complete.

You will need to renew the insurance credentials for your practice. The frequency depends on the company. Some require renewals every 12 months, others up to every 3 years.

The good news is that there are companies you can hire and software programs you can use to manage credential processes. This is a process that a competent office manager could track and care for. Once your practice is up and running, this is likely not an area on which to spend your time.

You must know that any time your practice is affiliated with a different employer tax ID number (EIN), you will need to obtain new credentials. Your insurance credentials do not move with you from one medical practice to another.

This depends on your practice type and the credential application you completed. There are some instances where medical practitioners can complete a group application; however, not all practices are eligible for this umbrella.

When a new medical professional joins your practice:

You already know you need to renew your credentials with the multiple insurance companies and agencies you will work with and to whom you will submit payment claims. Still, you should also be aware that you will need to validate that your CAQH information is current.

Due to the plethora of moving pieces in this overall process, it is best to:

Keeping this information organized while you are initially going through the process will save you an exponential amount of time later.

Obtaining insurance company credentials for your practice may initially seem drawn out and daunting. The good news is that you can complete many other tasks to move toward your goal of getting your practice up and running while you wait for various stages of the process.

Once your insurance company credentials are in place, you can accept your patients’ various insurance plans. Afterward, you can submit those claims to the associated insurance companies for reimbursement, or even better, outsource that function and have someone else manage the insurance billing process on your practice’s behalf.