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Credentialing Secrets No One Will Tell You


Here are the best insurance credentialing secrets we could give you!

Credentialing is one side of the business of private practice that is the most confusing and time-consuming process that you will likely enter. Since the credentialing process is confusing and complicated there is not a good resource that will tell you the ins and outs of insurance credentialing. Until now.


As a fair disclaimer, it is normal for the credentialing process to differ depending on the state that you are in and the company that you are trying to credential with, but there are some very clear tips and overarching processes that you can glean from this blog.


Here are some of the best credentialing tips we can offer!


What is credentialing (aka insurance payer enrollment)?

No insurance payer is going to give a contract to someone they know nothing about. Credentialing is the process of showing and proving your credentials (license, employment history, education, etc)


It does not matter what we believe, it matters what we can prove.


Credentialing Process

Preliminary steps:

  • Identify company structure (LLC, sole proprietor LLC, S-Corp, etc)

  • Gather information (see the this blog for a comprehensive list)

  • Identify which insurance you are going to credential with (need help deciding? Check out this blog)

Processing:

  • Document Review: Make sure you have everything in order

  • Processing – 2-5 business days:

  • Create or update CAQH

  • CAQH gets its own slide later

  • Acquire applications

  • Fill out applications

  • Submit electronically if no signatures are required possible

  • Send for signatures

  • Assemble and submit applications – 1-2 business days

  • Confirm Receipt – 2-3 business days after submission

  • Follow Up – Either payer’s cited turn-times OR 30 days, whatever is shorter

  • Continue following up until we get a yes or a no

  • Appeal if they deny the provider


From Onboarding through Completion, maintain a Google Spreadsheet with notes about submission dates, follow up dates, requested items, etc. This is the best and fastest way for providers to get status on their files.



Have you been credentialed before?

In our experience, insurance payers are more likely to give misinformation about how to update an enrolled provider than how to enroll a new one.


Important:

Many insurance payers will not allow 2 tax IDs on one provider contract, so if a provider wants to keep their full-time job and start a private practice part-time, they might require a full credentialing application process.


Pro Tip: Aetna and TriCare often have long or bumpy update processes. Cigna is generally very fast.


What information you need

  • Address, phone numbers, and fax numbers of locations   

  • Type 1 NPI for each provider

  • Type 2 NPI if applicable

  • Address, phone numbers, and fax numbers of locations

  • Tax ID

  • Copy of EIN letter from IRS (esp for Medicare)

  • Full legal name of business and filing status (LLC filing as S-corp, etc)

  • Provider specialties, populations (ages, areas of concern, etc) and evidence-based approaches to indicate in any provider databases

  • Provider’s standard work hours at each location (if not already in CAQH)  

  • CAQH login information

  • OR (if we’re setting up CAQH for the provider)  

  • Provider’s CV including month and year as well as address for all employment or college & graduate schools

  • Other names if applicable (unmarried name etc) and dates

  • Provider date of birth and SSN

  • Liability insurance

  • State license

  • Department clinician was in for internships

  • Any other certifications (CADC etc) being uploaded to CAQH

  • American Disabilities Act Compliance information for office (wheelchair accessible, bathrooms ADA compliant)

  • Proximity to transit


  • For Medicare:

  • NPI/PECOS login for provider

  • PTAN

  • OR (if company is new to Medicare)

  • EIN letter from the IRS

  • Voided check or bank letter for EFT

  • SSN and percentage of ownership for any company business owners

  • Type 2 NPI login (a must if they want checks to go to a company rather than individual)


  • For Medicaid:

  • Medicaid Login if existing

  • Company Medicaid ID if existing

  • Drivers’ license copy

  • SSN and percentage of ownership for any company business owners


Which Tax ID / EIN do you need?

You need the Tax ID and W9 for the company to whom the insurance payer sends the checks.


Some client groups hire independent contractors who form their own LLCs or PLLCs, and then you will need your contractors’ W9s, Tax IDs, etc.


This will not contract the provider with the group! Unless you want the insurance company to send checks to the provider, and the provider pays their employer. That is entirely between the group and provider, and would just muddy the waters with the insurance payer. Insurance companies don’t care how the group pays their providers.


CAQH

CAQH is a database that contains a provider’s CV or resume, as well as proof that everything on the resume is true.


Insurance payers like BCBS, Aetna, etc have access to CAQH once a provider signs an application.


If a provider doesn’t have a CAQH profile, you can create one for them.


If they have a profile, and they share their username and password, you can access their information plus documents like license, insurance, etc.


When an insurance payer requests the CAQH data, the provider will often get a notification that “[PAYER] has added you to their roster.” This does not mean they are credentialed. This means that the payer is aware of their existence and has requested their information. It’s confusing language so we get a lot of questions about it.


Who do I credential with?

We can give some general ideas of how it is to work with companies we’ve experienced, but we don’t know every company in every region of the US. We’re also exposing ourselves to liability if we say that Blue Cross pays best but the provider is disappointed by the contract rates.


Per insurance payer contracts, a provider is legally unable to disclose their contracted rates. We can’t really disclose who pays the best.


We often recommend providers talk to their local colleagues to get an idea of the insurance market in their area.


Insurance payers will send a fee sheet with a contract. A provider can decline to complete the application or contract if they don’t like the fees.


We have never run into an insurance companies that allows for fee negotiation up front.


Request to Join a Closed Panel / Appeals / Raises

You can absolutely create a letter requesting to join a closed panel, appeal a denial, or request a raise in insurance rates.


Information needed:

  • Specialties

  • Evidence-based modalities

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

  • Number of current clients on this insurance panel (esp if they are self-pay)

  • For raises, the range of what other insurance companies pay them – much stronger case if Payer A pays them $100 for 90837, Payer B pays them $95, and we’re asking Payer C to give them $90 instead of $70.

The research you need to do beforehand:

  • how many providers in their area provide those services

  • how many of those providers are in-network

  • statistics about how much their service addresses a need (ie addiction rates).


Some Extra Protips:

  • It is challenging to join Kaiser in CA or Priority Health in MI

  • We have not yet seen Anthem agree to a raise

  • At present, Magellan will only give a raise every 3 years

  • Cigna requires a provider be in-network for at least 2 years before they will raise their rates, and they often decline to do so

  • United will not give a raise during the first year. They have a new program that will offer an increased rate (of an unspecified amount) to providers who meet their top-tier criteria. Keep in mind United will call for a utility review if they have >20 sessions in 6 mos.


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