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  • Practice Solutions

Credentialing Series 4 of 4: Closed Panel and Denial Management


Main Points

  • Create a compelling letter describing why you should be allowed in the closed panel

  • Industry trends around credentialing

  • Items to consider when credentialing

One of the hardest parts of credentialing is receiving a denial or rejection for a request to join a panel. Not only does this put your plans behind, but it also prevents patients that you know from getting the care that they need.

With this reality it will be important for you to create a canned letter showing your value to the panel. Creating this letter should include the following:

  • Specialties

  • Evidence-based modalities

  • Number of requests you get from clients with this insurance panel

  • Number of current clients with this insurance panel

This will go to show the enrollment department that you are worth being on the panel and you will be requesting that they reconsider. Some of the time they will accept your case for an exception to the denial and will let you into the panel.

The other strategy for managing a denial or a closed panel is to develop a relationship with someone within the insurance company. Once you have this relationship, you can use that person to be your advocate on the inside.

However, if that doesn't work, then you will need to do one of two things. First, you can choose to move on and not be part of the panel, or you can choose to follow up every few months to see if they are accepting anyone on the panel.

Either way, you will need a fair bit of endurance to make sure that you are accomplishing what you are setting out to do.

At Practice Solutions, we do a good job of tracking industry trends based on our teams experience with the various insurance companies. Here are a few trends that we are seeing within the industry:

  • It is a challenge to join Kaiser in California

  • It is a challenge to join Priority in Michigan

  • Magellan will generally only allow a pay raise every 3 years

  • Cigna requires that the provider be in-network for at least 2 years before they will raise their rates

  • United Healthcare has started to accept pay raises, but historically has not

At the end of the day, you need to do what you need to do to grow your practice. If joining a specific panel is a critical part of your business plan or your practice then be persistent and don't give up. When credentialing be organized and clear with the insurance companies.

Keep every record that the insurance companies send you and document each and every phone call that you have with them.

Most importantly, try and have fun with the process! You can grow as a professional and as a person even through administrative toils!

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