New to Private Practice and Insurance Credentialing – What do do?

Health care providers who venture into private practice are often unsure how to set up their procedures for billing third-party networks for services. the billing and reimbursement process is called the “revenue cycle.” The first step in the revenue cycle is to obtain accreditation and a participating provider contract with the insurance companies that are important to your service area. Building a successful revenue cycle for a new practice can be a tricky business, but with a little planning you can make the process seem a little less intimidating. Let’s go over a few key steps in the process to give you guidance on setting up the revenue cycle for your new practice.

prepare for accreditation

credentialing is a process insurance companies use to verify your education, training, and professional experience and to make sure you meet internal requirements to serve as an in-network provider in their panel. Insurance companies are required to provide web-based provider directories that list all in-network providers for their plans. These online directories are regularly used by consumers of health care services to locate doctors and other health care providers who accept their insurance. The first step in implementing your new revenue cycle is to qualify and purchase the insurance plans that are relevant to your service area. Once completed, consumers will be able to locate you as a participating provider on their panel for their specific specialty.

Reading: How to get contracts with insurance companies

The process of “credentialing” or “provider enrollment” with an insurance network actually consists of two phases. 1) accreditation and 2) hiring. The credentialing phase is when the insurance company verifies all of your credentials and that you meet the requirements to participate in their network. the contracting phase is where the company issues you a participating provider agreement that defines the terms of participation to receive in-network reimbursement for your claims.

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Without a participating provider agreement, you will not receive in-network reimbursement. Until your credentialing and contracting is complete, you may have the option to bill the network as an out-of-network provider, but there is no guarantee that your claim will be processed. Whether or not your claim is accepted depends on whether the patient’s policy has out-of-network benefits. government health plans, like medicare and medicaid, will not pay for any out-of-network services.

Which insurance companies should I accredit myself with?

Consider asking a fellow practitioner in your area or the manager of the office that handles billing in your area which insurance companies provide the largest patient base in your area. that practical knowledge about local insurance companies can be valuable. Major national plans to consider include Aetna, Blue Cross Blue Shield, Cigna, United Healthcare, Humana, Medicare, and Medicaid. There are many Medicare Advantage Plans as well as Managed Medicaid Plans for your consideration. there are also some major national ppo plans that lease their network, such as multiplan, which may be important in certain areas.

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checklist items for credential and contract preparation:

  • Consider setting up a business entity to practice under (llc, s-corp, pc, etc) and get your tax ID
  • if you operate as a sole proprietor, consider getting a federal tax id to operate in lieu of your ssn
  • get your professional liability insurance policy
  • get an npi number for you individually (type 1) and your business entity (type 2)
  • be fully licensed in the state where you will provide services (including prescriptive authority)
  • create a profile with caqh and keep it updated
  • have your practice location ready
  • Know which insurance networks you want to participate in
  • accreditation with insurance networks

    insurance credentialingThe process is time consuming. Once you have prepared for the process and know which insurance companies that you want to participate with, it’s time to get started. Expect to spend anywhere from 2 – 6 hours on each application when considering application preparation and follow up throughout the entire process. In many instances it will make economic sense to outsource this important revenue cycle step while you focus on treating patients or work on other business building activities.

    Many doctors and other health care professionals starting a new practice who previously worked for another organization often think that since they are already in-network with an insurance company, little or nothing needs to be done for their new private practice. in many situations, those providers were participating under the previous organization group contract that will not transfer to the new private practice. do not assume in these situations that your accreditation process will be faster with insurance companies. Contact each plan to determine the status of your contract and for instructions on how to set up your new practice. some will require you to go through the entire process from the start, others may have shortened processes to get a new private practice contract issued. If you were participating with the previous organization under an individual contract, then you can transfer your contract to your new private practice. the process varies greatly depending on the plan.

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    Please note that the credentialing process can take several months and many insurance companies may not accept new providers on their panels. Also, networks may not accept new providers in your service area. in which case, your options are to appeal their decision (successful appeal is extremely rare) or continue to apply every six months if available. If you were participating in a network under a previous employer or organization contract, you may still receive a denial to issue a participating provider contract if the network is not accepting new providers in your area, as the contract would be a new problem for the network.

    checklist to start the process

    • Contact your network provider’s service department to inquire about their credentialing process and obtain a credentialing application. most plans have applications and information on their website, like here with aetna.
    • Take the time to fully fill out your application listing all service locations for your practice, sign and date your application, and include copies of all required documents
    • Make sure your caqh profile is up to date with all information, in particular practice location information and include copies of all required documents such as license, insurance, board certifications, etc.
    • keep a copy of your completed and submitted application
    • verify with the insurance company that your credentialing application was received and follow up regularly with the insurance network until your credentialing is complete and you have an in-network effective date with a participating provider agreement
    • respond to any requests for additional information the insurance company may have
    • Document all of your follow-up activities as you go through the accreditation process
    • review your participating provider contract for details of your network provider requirements, claim filing procedures, fee schedule for your services, timely filing limits, and all other important contract terms
    • Keep copies of all submitted accreditation applications and contracts. be sure to keep a final copy of your network agreement
    • at the end

      When the credentialing process is complete, you’ll be ready to begin billing the network for services. here are some key things to remember about maintaining your credentials:


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