Credentialing: Are You on the Game Board?

Credentialing is the first step to putting a provider to work at a facility. You may have started your private practice to focus on patient care, but the business side of healthcare can often feel like a demanding, mysterious puzzle. If insurance billing is the game, then getting credentialed is your first and most critical move. It’s the process of verifying a healthcare provider's qualifications, training, licenses, and competency to provide care and join an insurance company's network.

But what happens when you think you're credentialed and your claims are denied? Credentialing errors and inconsistencies are one of the most common, and avoidable, causes of subsequent claim denials and rejections. Incorrect or missing information in your application can lead to significant delays, and if not caught, can mean that your claims get denied and you don’t get paid for the work you do. This can be incredibly frustrating.

We wanted to pull back the curtain on this “black hole of healthcare”. In a recent episode of The Claim Game, we interviewed Cathy Gilbert, a "game maker" who has spent decades shaping the credentialing landscape from the insurance company's perspective. Her insights are a game-changer for any practice owner.

Here are three key takeaways from our conversation with Cathy to help you win The Claim Game.

1. Credentialing is a Dual Effort

You might think that your practice’s job ends once you hit “submit” on a credentialing application, but the reality is that credentialing is a dual effort between you and the insurance company. Your practice is the source of truth about your information.

This means it's your responsibility to keep your data current and up-to-date in CAQH and with the plans you are paneled with. CAQH is considered the "gold standard" for provider information, and it's what most plans use to pull your data. But CAQH is only as accurate as the information you provide and keep updated. Plans will regularly reach out via email, phone, or mail to validate your information. If you don't respond or update your information, they could remove you from the provider directory and even dis-enroll you from the network. This means you could lose your ability to get paid for in-network claims. The key takeaway here: keep your data current in CAQH because it directly impacts your claim getting paid.

2. The Credentialing Process Is a Black Hole (But There Is a Path Through It)

Many providers feel like credentialing is a mysterious black hole, and they’re right. Cathy shared that while she was on the payer side, she had small teams managing networks of up to 300,000 providers. They genuinely want to help you, but due to the sheer volume of applications, they must prioritize. It’s a first-in, first-out process, and they have to focus their limited time and resources on high-volume providers and key markets. So, what does this mean for you?

First, don't start "bugging" them before the timeframe they provide. Most plans state a timeframe for processing applications, and repeatedly calling to check on the status won’t move your application to the top of the pile. Instead, it takes time away from their team. A good rule of thumb is to wait until you are beyond the stated timeframe to call or follow up.

Second, save your confirmation! When you submit an application, you usually get a confirmation window or an email acknowledging receipt. Take a screenshot or save that email. It serves as your official record and helps you know that your application was received.

Third, if you're hitting roadblocks, you can find your provider relations representative on the payer's website or by doing a search on LinkedIn. They are there to help with complex issues and can often guide you through roadblocks.

3. Know What You Can Negotiate in a Contract

When you finally get to the contract phase, you might assume it's a "take it or leave it" situation. While many contracts are boilerplate, there are a few terms that may be negotiable, but they may extend the time it takes to get credentialed.

First, you might be able to negotiate a longer timely filing period. While most plans have a 90-day filing limit, you may be able to ask for a longer one if you need it.

Second, you can ask about the notice requirements. A provider manual or handbook is often considered an extension of the contract, and payers will often use a “silence is acceptance” clause when they change policies. You might be able to negotiate for a clause that requires you to sign any changes.

And the big question: are rates negotiable? The answer is "maybe". You may be able to negotiate a higher rate if you are a specialist in high demand (like a child psychiatrist) or if you are in an area with a need for access. You might also be able to sign up for a program for providers that offer immediate access to care for new patients. These programs often have a higher fee schedule.

Ready to get a handle on your practice's financial health? The first step is to master the rules of credentialing. To listen to the full episode, or for more resources on billing and revenue cycle management, check out our podcast at practicesol.com/podcast. If you'd like to learn more about how Practice Solutions can help your practice, visit practicesol.com/contact to connect with one of our awesome team members.