Are you tired of searching for easier and quicker ways to get credentialed with insurance companies? If you are like most doctors, becoming an in-network provider can feel frustrating due to endless paperwork, countless verifications, and tight deadlines. The biggest challenge? Figuring out what the insurance companies actually want. You can find information from various sources online, but it is so technical that it only adds to the confusion.
We are here to help with that! This article simplifies the information so you know what steps to take, what documents to gather, and how to avoid common mistakes. Before taking any action, let’s confirm whether we are on the same page regarding provider insurance credentialing.
What is Provider Insurance Credentialing?
Provider insurance credentialing is the required verification process set by insurance companies. To be more specific, it includes a series of steps through which healthcare providers, such as doctors, nurses, and other medical professionals, become qualified to receive reimbursements from a payer.
This comprehensive process is quite different from contracting. It often involves a full professional check where insurance companies verify everything, from your qualifications, licenses, and regulatory compliance to any past liabilities and citizenship.
Keep in mind that credentialing with insurance companies has several conditions.
- Firstly, you must be a certified doctor or any other healthcare professional to initiate this process.
- Secondly, you will need to go through different credentialing processes as each payer has its own requirements.
- Finally, you must constantly update your information (insurance companies will re-evaluate your credentials every 2 to 3 years to make sure you continue to meet their standards).
So why is it important to become an in-network provider? It significantly reduces out-of-pocket medical expenses and helps healthcare organizations avoid legal consequences.
Getting Credentialed with Insurance Companies
You can follow these simple steps to initiate and successfully complete the credentialing process with insurance companies.
Research Insurance Companies & Understand Their Requirements
Did you know that not every insurance provider or plan is available at every location? Therefore, the first step to getting credentialed with insurance companies is to identify all the payers in your area. Don’t know where to look? Consider regional payers alongside major national insurance companies like CVS Health, Blue Cross Blue Shield, and Humana, as well as federal programs like Medicare, to determine which networks you wish to join.
Want to know the best way to conduct market research? Analyze where your potential patients are likely insured. Additionally, find out which insurance companies your competitor practices work with.
After compiling a list, the next step is to understand their requirements. Since each payer has unique demands, visit their website or call their customer representatives for guidelines. Inquire about open panels. Want to know a pro tip? Type “[insurer’s name] provider credentialing” in the Google search bar to get started.
Gather Required Documentation
Already have a list in your hand? The next step is to gather all the relevant details required for credentialing with insurance companies. This includes preparing necessary documents, such as:
- Medical licenses and certifications
- National Provider Identifier (NPI)
- Medical Professional Liability (MPL) / Medical Malpractice Insurance (MMI) details
- Professional work history
- CAQH ID
So, what exactly is CAQH? Formerly known as CAQH ProView, CAQH Provider Data Portal is a central database where healthcare providers enter their information. Many insurers require healthcare providers to have an up-to-date profile on this portal for insurance credentialing. Don’t forget to upload a valid malpractice insurance certificate to your CAQH profile.
Apply to Join the Network of Each Insurance Company
Have you gathered all the required information? Now, submit your applications to the insurance companies you wish to join. You can also outsource this process to a third-party company to avoid common mistakes and save time.
Follow Up
Don’t forget to follow up with insurance companies. Credentialing with insurance companies often requires constant communication. So, keep checking your emails and promptly respond to any additional requests to keep your application moving until you reach the contract negotiation phase.
Negotiate & Finalize the Contract
You can move to the contract phase when the insurance company approves your application. At this stage, you will demonstrate your negotiation power. The insurer will propose a fee schedule with detailed reimbursement rates (the amount they will cover) for various services.
Our advice? Review all the details thoroughly and negotiate if the rates are lower than your expectations or inadequate for your services/practice before signing the contract.
Wait for Final Approval
After signing the contract, wait for the insurance company to finalize your credentialing. You can start seeing patients and filing claims once the payer sends you a fully signed copy of the contract with the effective date of your in-network status.
Re-Credentialing
Almost all insurance companies re-evaluate your status every few years. So, make sure you stay compliant with their standards and keep your CAQH profile updated to maintain your credentials.
Challenges in Getting Credentialed with Insurance Companies
It is not easy to join an insurance network. It involves an endless list of requirements and hurdles. You may want to complete this process as soon as possible to receive timely payments, but even a small mistake can hinder your progress for weeks. Here are some of the most common challenges healthcare providers face when getting credentialed with insurance companies.
Complex & Varying Requirements
Insurance credentialing requirements are not only complex but also vary significantly from payer to payer. There is so much to do, from gathering numerous documents and creating a CAQH profile to providing proof of malpractice insurance, all while complying with different regulatory standards. These variations often lead to confusion and errors, resulting in application delays and rejections.
Closed Panels & Market Saturation
Market saturation is the biggest challenge in getting credentialed with insurance companies. Insurers usually don’t add new providers to their panels in densely populated or well-served regions. However, there is a slight chance of overcoming this problem. You can persuade insurers to include you in their network if you have a larger patient base than an established practice.
Increasing Demand for Experience
Some insurance companies require physicians to have a minimum amount of experience, often up to 6 months, before considering them for credentialing. This condition varies among payers and is a significant hurdle for newly licensed doctors.
Time-Consuming Process
Let’s face it! Time is a valuable asset in the healthcare industry. Credentialing with insurance companies is a frustrating process for many providers because it consumes a lot of their time. The entire process, on average, takes 120 days to complete, whether you are starting a new practice or hiring a new healthcare provider for your existing clinic. Gathering the necessary information alone usually takes up to 10 hours, which is only the first step.
Insurance credentialing is also prone to delays, often due to back-and-forth communications and additional requirements. Therefore, many practices and individual providers hire outsourcing companies to handle everything.
Benefits of Getting Credentialed with Insurance Companies
Getting credentialed with insurance companies might not be easy, but it definitely brings incredible perks and opportunities for growth. You can gain the following benefits by becoming an in-network provider:
Improved Cash Flow
Credentialed providers are eligible for reimbursements from various insurance companies. This results in timely payments, which leads to a more stable income stream.
Reduced Legal Risks
To maintain your credentials, you must satisfy all regulatory and payer-specific benchmarks, including implementing data security measures to protect patient information. In simple terms, insurance credentialing helps healthcare providers avoid potential lawsuits and other legal issues.
More Credibility
Patients generally view credentialed providers as more trustworthy and credible. Getting credentialed with insurance companies can improve your reputation, increasing patient satisfaction and trust.
Larger Patient Base
Credentialing increases visibility. When you join the network of national, regional, and supplemental insurance companies, your services become accessible to a larger pool of insured patients, effectively expanding your patient base.
Builds Patient Trust
Credentialing verifies your qualifications and competence, facilitating stronger patient-provider relationships. Patients prefer credentialed providers for receiving error-proof, quality patient care.
Consistent Reimbursement
Getting credentialed with insurance companies reduces the risk of underpayments. With set reimbursement rates from insurance companies, you can anticipate payment amounts and effectively manage your revenue cycle.
Outsource Insurance Credentialing to MediBill MD
Do you still feel overwhelmed with the never-ending credentialing requirements? You can always opt for outsourcing. If your practice already has a billing partner, chances are that they might also handle your credentialing with insurance companies. Otherwise, you can rely on MediBill MD’s expertise.
Our medical credentialing services simplify your enrollment in top insurance networks, making you eligible to provide patient care and file for reimbursements. We serve all types of healthcare providers, so you don’t have to stress over paperwork or deadlines. From qualification verification and application submission to contract negotiation, we handle everything at incredibly affordable rates.
So, instead of worrying about different payers’ requirements, partner with our experts to make your credentialing process more efficient.
