All Credentialing

Insurance Credentialing For New Health Care Practices

Launching a healthcare practice demands persistence, resources, and meticulous planning. While all startups face many challenges, medical businesses grapple with more hurdles. Practitioners must navigate a maze of regulations, licenses, and equipment needs. Each step requires careful consideration, from securing suitable premises to hiring qualified staff. Despite these obstacles, many find the journey rewarding. The chance to serve their community’s health needs drives them. Success hinges on balancing clinical skills with business savvy. It’s about turning a vision into a thriving medical firm.

In a healthcare practice, you must ensure your “clients” can pay for your services. Your clients will give you a plastic card to pay for your services at a medical office. I’m talking about an insurance card, not a credit card, though you will see those too. You must ensure that the plastic card is valid. It must cover your services, and the company behind it must pay your claim. How do you ensure that your claim gets paid? The simple answer is “Credentialing.”

You can call it many things. Insurance credentialing, payer contracting, managed care contracting, provider enrollment, or credentialing. They all mean the same thing. It ultimately comes down to applying to insurers to become an “In-Network or Participating” provider. As “in-network” providers, participating providers can bill insurance credentialing for new healthcare practices get paid. This usually means paying your claims on time and at a previously agreed-upon rate.

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Who should I participate with?

That is a geographically specific question. You must enroll with the major national companies, such as BCBS, Aetna, UHC, Cigna, and Humana. Also, enroll in important government programs: Medicare, Tricare, and your state Medicaid. But some unique regional players may be important to you, without a doubt.

Large local employers often use complex insurance networks. Some self-insure, leasing physician networks from national firms or building their own. Others rely on administrators from outside the company to manage claims. Navigating these systems can in no time turn into a maze of options. Conduct comprehensive research to uncover which networks matter most in your area. This landscape is crucial to understand. But, it is hard due to the complex web of healthcare relationships.

If you have peers in the same market, ask their company manager who the significant payers are in your area. The hospital where you have privileges can help you identify those payers. Please ask their billing managers.

Stay vigilant as payer relationships evolve. When a surge of new patients brings unpaid claims, verify enrollment status. This vital practice needs constant attention to keep your medical office running smoothly. Adapt your participation strategy as needed to maintain a healthy revenue stream.

When do I start the credentialing?

Start the insurance credentialing services process early. You can be limited until you have office space, a bank account, and a business organization. But, plan ahead for the credentialing process. Organize and make your background docs, licenses, CV, and insurance easily accessible. Also, keep copies of all relevant documents. Make sure your CV shows your full background since you graduated medical school. Also, each entry for education, training, and jobs on that CV must include the month and year. It should take 6 to 9 months to get in network with 8 to 12 carriers in your market.

Although every carrier will have their unique procedure, they all essentially follow the same one. First, you go through “credentialing”. They verify your education, training, work history, and licenses. They also check your hospital privileges, references, and other backgrounds. When all primary source verification is complete, the “Credentialing Committee” reviews your file. In 90 to 120 days, this process should be completed.

If the medical credentialing services committee approves you, then you move to step two: “Contracting.” Contracting is the point that you receive a provider agreement to execute. You can review the contract and try to negotiate better terms before signing. The carrier representative does the same when you sign and submit your contract. After that, a mail saying “Welcome to the network” is sent. You should give this process 30 to 60 days.

Given how long it takes carriers to complete the process, you can see why it’s vital to start early. Don’t expect to complete all of your credentialing over the phone a month before you wish to open. And don’t think you can backbill insurance companies once your contracts are in place. Medicare won’t allow retroactive billing for your services or “in-network” rates. The rule is in effect for 30 days prior to that date.

Your claims will be handled as out-of-network until you are in the carrier’s network. So, you won’t get much, if any, reimbursement from the insurance company. For out-of-network claims, you will need to collect payment from your patient because some insurers reimburse the patient directly. Until you are in network, the best bet is to collect your services from the patient at the time of service. After that, provide them with a claim form to send to their insurance provider. If you plan to accept a patient’s insurance, you may want to “match benefits.” That means only charging them what they would have paid if you were in-network. This entails merely receiving a portion of the money. But, after your contracting process, you’ll be more likely to keep and treat that patient in the future.

Initiating the Credentialing Process:

Establishing network participation with payers is crucial for a thriving healthcare practice. Credentialing can be a challenging and time-consuming procedure, even if it is essential. Here are the key steps to initiate and manage credentialing effectively:

Step 1: Network Identification and Initial Contact

Begin by identifying the target networks crucial to your practice’s success. Contact their provider services departments to:

Confirm network availability in your service area for your specific specialty.
Inquire about their enrollment process and required documentation.

Some payers offer online applications, while others utilize paper forms. Be prepared for a potentially lengthy process, regardless of the format. If a network is closed in your area, ask about future availability and set a follow-up schedule.

Step 2: Document Compilation

Gathering supporting documentation is a critical step. Keep a checklist of required documents. They are needed for various applications. This approach will save time and prevent delays later.

Step 3: Application Submission and Consistent Follow-Up

After submitting your application and supporting documents, consistent follow-up is paramount. We recommend a three-pronged approach:

Confirm Receipt: After submitting, check that the payer has your app and it is “in process.”
Regular Monitoring: Set a follow-up schedule (every 15-30 days) to check your app status. This lets you quickly find and fix any missing info or issues.
Persistence is Key: Applications can sometimes get lost. This can happen due to misrouted emails, transmission errors, and lost mail. Be prepared to resubmit if necessary.

Consistent follow-up is not about speeding up the process. It’s about keeping your application active and avoiding delays from admin oversights.

Step 4: Application Completion Notification

After the credentialing process, you will usually get a notification. It will be by letter, email, or fax. It confirms your participation status in the network.

Timeline Expectations

Be realistic about the timeframe. Each payer can take 60 to 180 days, or more, to complete the credentialing and contracting process. Starting on the day they get a completed application, that is. So, it’s vital to start the process well before your desired date.

Practolytics: Your Credentialing Partner

In-house credentialing services can waste resources needed for patient care. Practolytics offers comprehensive physician credentialing services designed to alleviate this burden. We provide:

Full Provider Enrollment Solutions: We handle all credentialing and contracting. This ensures a smooth, efficient process.
Expert Advice: Our staff provides knowledgeable counsel and assistance. We will navigate complex rules and regulations.
Proactive Follow-Up: We handle all communication and follow-up with payers. This saves you time and effort.
Reduced Administrative Burden: Outsource your healthcare credentialing services to Practolytics. Your staff can then focus on patient care and other important tasks.

Summary:

The insurance credentialing process is a vital investment in your practice’s financial health. Starting early is key. It ensures timely participation in payer networks and quick cash flow. It can take time. But, partnering with Practolytics can ease admin work and streamline the process. Contact us today. Let’s discuss your credentialing needs and how we can help your practice thrive.

Navigating the intricate hospital credentialing procedures is necessary when starting a healthcare practice. From identifying target networks and gathering required documentation to filing applications and meticulously following up, this article lays out the crucial processes. It highlights how crucial it is to begin the medical credentialing process as soon as possible because it may take many months to finish. The advantages of working with a credentialing service like Practolytics are also highlighted in the blog. In the end, outsourcing this important operation can improve your practice’s revenue cycle by ensuring compliance, reducing administrative stress, and speeding up the process. New practices can build a solid basis for success by concentrating on patient care and leaving certification to professionals.