Insurance credentialing is the way insurance companies verify that medical providers are legitimate and qualified to receive reimbursement for services provided. When a provider is credentialed with a given payer, they can bill the payer directly and receive reimbursement.
Credentialing is no different from a job application. Accurate and timely medical insurance credentialing is essential for practices to get paid by insurance companies. It’s complicated, time-consuming, and can cost you hundreds of thousands of dollars in lost revenue if you get it wrong.
Every practice that wants to bill an insurance company needs to be credentialed. This includes hospitals, clinics, physicians, chiropractors, dentists, physical therapists, behavioral health therapists, occupational therapists, optometrists, and social workers.
Overview of Insurance Credentialing
Getting credentialed (or on insurance panels) involves retrieving and filling out a series of applications with insurance companies. This can take upward of 10 hours per panel. It then includes submitting the applications to insurance companies, ensuring each has received your application, and then doing a lot of follow-up to track the progress of each application.
While it seems like there are only a few steps, which sound simple enough to complete, health providers often describe the process to be “nightmarish”. This is because the application process rarely goes smoothly, and many providers find themselves resubmitting applications, fighting enrollment rejections, and spending a whole lot of time “on hold” with insurance companies. Additionally, many of the panels that you apply to may say that they are full or are not accepting people with your specialty at this time.
Therefore, it is no secret that the process of medical credentialing isn’t something many healthcare providers look forward to — in fact, many healthcare providers dread it. However, here are a few things you can remember that will make the process easier:
Make a List
Research the insurance companies and find out which insurance companies you want to be credentialed with. Each company may require a different process with varying hoops you have to jump through.
Get Prepared, and Complete the CAQH
CAQH, the Council for Affordable Quality Healthcare, is often needed in conjunction with an insurance company’s application to complete one’s medical credentialing (i.e., to get on insurance panels). Major insurance companies, like BCBS and Aetna, use CAQH as a part of their application process.
There are a few important things you need to know about your CAQH application…
You need to be invited
You can’t just go on to CAQH and upload your information; you need to be invited by an insurance company. This creates a near “Chicken or the egg” situation where you need to first submit an application to an insurance company. Then, call that company about two weeks later to see if they received the application and have generated a CAQH number.
Only then can you go to CAQH, and complete the application, which is sent to the insurance company, which needs it to complete your application.
Never opt to fill out your CAQH on paper
CAQH offers medical providers the option to complete the application online, or on paper. Don’t choose the paper option.
First, the application is 50 pages long and only prints correctly in color. Second, and most importantly, when you submit a paper application to CAQH, they need to hire a data entry person to transfer all your information. This never gets done. When you call to ask what happened to your paper application, they simply recommend you complete your CAQH application online.
Your resume must be perfect
One of the trickiest parts of getting a CAQH application completed is to make sure your resume is perfect. First, your dates of employment and education need to be in Month/Year format. If you don’t post dates, they reject your application and won’t send it on to the insurance companies. Secondly, make sure there are zero gaps in your employment history.
Don’t forget your re-attestation
Four times a year you’ll receive an email from CAQH, asking for you to “Re-attest” to the information in your profile. Not doing this can cause major problems with your ability to accept insurance, as the insurance companies you are paneled with will know the lapse in CAQH.
Re-attestation only takes a few minutes (if you can remember your provider number and password), so log in and get it taken care of ASAP.
Expect to devote about 10 hours to every insurance panel you wish to be credentialed with.
Expecting that credentialing is going to involve just a few minutes of filling out an application will lead only to frustration. Instead, expect 10 hours of focused labor for each company you want to be credentialed with. This time will include retrieving applications, filling out applications, organizing necessary documentation, and following up with insurance companies by telephone.
While some applications are electronic, the vast majority need to be printed and completed by hand.
Follow up with the insurance company often.
Insurance companies have a way of losing provider applications, or putting them in “limbo”–where they are not being reviewed properly and the medical credentialing process goes nowhere. The problem with credentialing application “limbo” is that if an application is stuck there for more than a few weeks, it might expire and be automatically rejected, leaving the provider (that’s you) with no option but to start again, from step one.
Hence, you will want to call each insurance company every time an application (or any documentation) is faxed, emailed, or mailed to them. After that, you will want to call every insurance company about every 2 weeks, to check up on the status on your credentialing applications.
Consider getting medical credentialing help
For many health professionals, it makes pragmatic sense to find a reputable service to help with medical credentialing. Not only does using a credentialing service alleviate the frustration and headache of the process (many providers have heard the ‘nightmare’ stories from their colleagues), but using a service may also save money. Also, a reputable service will likely have better success getting you credentialed efficiently. This means you can start seeing those clients with insurance sooner, rather than later.
Also, refer to https://credentialing.com for other details.
Process of insurance credentialing
For Commercial Insurance networks, this process involves two steps: Credentialing and Contracting.
This step is for the provider to submit a participation request to the health plan using their credentialing application process. Insurance credentialing application processes vary from completion of a unique credentialing application, use of CAQH, or acceptance of a state-standardized credentialing application.
When the health plan receives a credentialing application, they perform a thorough credentials verification of the provider to ensure he/she meets their credentialing requirements. When all credentials verification (Primary Source Verification) is complete, their credentialing file goes to the Credentialing Committee for approval.
Expect networks to take up to 90 days to complete this process. Once approved by the Credentialing Committee, the second phase of the process begins.
The Contracting phase of enrollment is when the provider has been approved by Credentialing and is extended a contract for participation. Most commercial insurance networks have staff dedicated to the contracting process which is separate from the credentialing step.
In the contracting phase, you review the language of the participating provider contract, reimbursement rates, and all the details and responsibilities of participation, then sign your agreement. This is the phase where you begin the negotiation of rates if the standard reimbursement rates don’t meet your expectations.
Once your agreement is signed and returned to the network, you receive an effective date and provider number so that you can begin billing the plan and receiving “In-Network” reimbursement for your claims. Expect networks to take 30 – 45 days for this process (after credentialing is complete).
Medicare insurance credentialing
Provider Enrollment in Medicare, Medicaid, Tricare, and other government health programs is a bit different. These programs have standard forms that must be filled out and sent to the appropriate intermediary that handles all the administrative functions for the program in your jurisdiction.
Medicare reviews your application against strict enrollment standards. You may find extensive enrollment information on the CMS website regarding the Medicare enrollment process. Some key items to remember when applying for Medicare include:
- You must have a primary place of service in operation (or in final preparation)
- You’ll need banking information to set up EFT payment for your Medicare reimbursement
- You must provide the personal details of every individual having an ownership stake in your practice
- Supporting documents vary with the type of provider enrolling
- Citizenship documents are required for providers born outside the U.S.
- ECFMG certificate is required for providers’ education outside the U.S.
- Sign your application forms correctly in every signature location
The Medicare enrollment process is very detailed. It is always wise to have someone experienced in Medicare enrollment review your application prior to submitting it.
Regardless of who is handling your insurance credentialing applications, the primary thing to consider is DO NOT WAIT. The process can be lengthy and you won’t receive “In-Network” reimbursements until your contract is in effect. Medicare is a bit different in that you can bill 30 days prior to the date they receive your application (your “Effective Date”).
So if Medicare takes 60 days to complete your application, you can back bill to your effective date; but commercial carriers don’t allow that type of back billing.
How long does insurance credentialing take?
The credentialing process usually takes between 90-120 days, from start to finish. Because of this, if you are getting ready to start a private practice, don’t wait until the week before you open your doors to start the process!
How long do I need to be licensed to get on insurance panels?
The answer can get complicated, as the rules change by insurance company, and by state. However, in most instances, healthcare providers who are fully licensed (not intern-level or intermediate-level licenses) can get credentialed with most insurance panels.
However, there are exceptions. UBH and United Healthcare like their providers to be practicing for a minimum of 2 years post-licensure, and Value Options requires three years of post-license practice. On a positive note, in most states, Blue Cross, Blue Shield, Aetna, Cigna, Humana, and many others have no post-licensure waiting period.
What’s so hard about credentialing?
It’s not a difficult process. However, it is very complicated and time-consuming. A single application to a single payer typically takes 20 hours or more. Every state has different requirements. So does every payer. Specialties can require unique documentation as well. All of these variables make it easy to miss a step, attach the wrong version of a document, or otherwise make mistakes.
What are the timeframe requirements for credentialing?
Providers have between 30 and 90 days after the day of service to submit a claim, depending on the state and payer. Payers then have 90 to 120 days to pay on that claim. If the claim is rejected and then resubmitted, the waiting period starts all over again. However, the payer’s 90-day clock does not reset if a claim is denied.
Providers could be faced with timely filing issues if they see patients when they are not credentialed properly with payers. Payers will not process claims that occur when the provider is not credentialed. Time can easily run out, and the provider will never be paid for work done.
Once you’re credentialed, is that it?
Unfortunately, no. Commercial payers like Kaiser Permanente and United Healthcare require re-credentialing every 1 to 3 years, depending on your area of practice. Medicare requires it every 3 to 5 years.
If your practice has many payers, they will all demand reapplication on different dates. Re-credentialing can be just as time-consuming as getting approved in the first place.
The biggest problem for many practices is that they drop the ball and forget about revalidation. They don’t realize what’s wrong until they start getting denials. By that time, it’s too late to refile.
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