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The Credentialing Process Made Simple!

The credentialing process has been complicated...until now!


The necessity for understanding the credentialing process has never been more important as it has been recently. Over the past few months, providers have flocked to an insurance-based model of private practice because of the global economy has supported less private-pay practices. In this blog, we will break down for you the step by step process that insurance uses to credential providers and give you the best tips that we can offer along the way.

1. The first step in the process is to submit an application to join the network to the insurance company or companies of your choice.

This process is probably the most important process for you as the provider. This process will include gathering all kinds of information so that the insurance company can prove who you are. Credentialing is the process of obtaining, verifying, and assessing the qualifications of a practitioner/provider to provide care or services in or for a Healthcare Organization. Credentials are documents of evidence of licensure, education, training, experience, and other qualifications. You will need a lot of documentation to prove this. If you haven't already done so, check out this blog to see the complete list of things that you would need in order to fill out the application.

Filling out the insurance application and sending in the appropriate documentation is very important and needs to be done with care and concern.

Tip #1: Start Early! Plan to start the credentialing process 120 days prior to seeing clients and make sure that you are submitting all the documentation with correct information. Any wrong move on the application could result in delays in your ability to see clients.

2. The second step is that the insurance company conducts a primary source verification.

This means that the insurance company is going to call your college, the licensing boards, previous employers, internships, practicums, fellowships, and they will follow up with your malpractice insurance for up to 10 years. During this stage of the process if the insurance company finds any malady among your history or credentials, or if they can not verify that you have the experience that you claim that you have, the insurance company will deny your application. This is why it is so important to be detailed. Remember, the insurance company is in no rush to fast track your application at this point. They will make whatever effort they need to in order to obtain verification that you are who you say you are.

Don't be alarmed if the insurance company contacts previous employers. This is a normal process that the insurance company undertakes to be able to credential providers.

Tip #2: Be Detailed! Don't paint over details or go quickly. Allow yourself plenty of time to be able to finish the application and ensure that all of your information is accurate. Insurance companies are not in any hurry to get you credentialed and they will reach out to your primary sources until they speak to someone. It is important to have the exact right information at all times.

3. The third step is that your application and primary source verification is sent to the health plan's credentials committee for review

This is the important part! This is where your application will be reviewed and either approved or denied. Once your application arrives with the credentials committee there is not a lot that you can do in order to alter their decision. You will likely hear from the committee in the form of an email or letter stating that you were accepted or denied.

If accepted, this does not mean that you can see clients and submit claims! This is important! It means that you are moving onto the next stage of the process but if you submit claims at this point they will likely be denied since you are not technically in the system. It is at this point that you might wait for the longest to hear from the insurance company.

Tip #3: Be Consistent! Regularly and actively follow up with the health plan about the status of your application. if the representatives tell you that your application is still in review, that is okay! Make sure that you are documenting your follow-ups and be sure to follow-up next week!

4. The fourth step could include a site visit It is very possible that the insurance company conducts a site visit to your office if they have questions or concerns about anything. It is possible that the insurance company wants to make sure that you are where you say you are and ensure total compliance with ADA rules and HIPAA regulations. Often times, insurance companies forgo this option in the mental health world because of the lack of blood testing or actual physical examination, but you should be prepared for this step anyway. Tip #4: Be Professional! You will want to be polite and courteous to the insurance company representatives because they are going to be paying you for services and you want to be on their panel. Have a clean office space that is welcoming and make sure the insurance company has a good experience interacting with you. 5. The fifth step is the insurance company will add you, your tax ID, and all of your information into their system This is an important step in the process because the information that is added to their system is the information that will dictate what information you send on claims in order to get paid. If the information is loaded into the system incorrectly claims will be submitted and might not be processed. Often times you cannot control this part of the process, but you can escalate a problem if you find one. Tip #5: Escalate Issues! At this point in the process, you have continually followed-up with the insurance company and maybe you are checking to make sure the insurance company is loading your information correctly. If you find out that the information has not been loaded correctly, you may need to escalate the issue to a manager. Again, be professional but also ensure that the insurance company is going to pay you with the right information. 6. Congratulations! The last step is that you are added to the plan's network At this point, you will likely receive a welcome packet in the mail or via email. This packet will include your contract, fee schedule, and any other important tools and resources that you might need to successfully work with this health plan. It is at this stage of the process that many insurance companies will provide you will a fee schedule so you know what you will be paid. It is at this point that you will need to do some math to see how that will impact your bottom line in the coming months and years working with this particular insurance company. The other exciting part of this process is that you will be added to the insurance company's website so people can search for you and sign up for sessions! This is the main benefit of paneling with an insurance company. Tip #6: Delegate! At this point in the process, you may want to delegate the billing processes to a professional or someone that you know because that is going to be an ongoing process and can consume a tremendous amount of your time. Congratulations on making it through the process! Don't hesitate to reach out to us if you have any questions and we would be more than happy to answer any questions that you might have!

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