Insurance claim form with stethescope on top of itHealthcare organizations, payer networks, and hospitals require insurance credentialing to accept a provider within their network or to treat patients at their facility or hospital. However, the insurance credentialing process is filled with complications that can frustrate even the most patient of practitioners. The good news is that time can be saved, aggravation can be spared, and insurance credentialing rejection can be avoided.

Why Insurance Credentialing?

Credentialing involves the acquisition and evaluation of documentation regarding the medical provider’s training, education, license work history, regulatory compliance record, and malpractice history (if any). If a doctor does not have the proper credentials from the insurance company, Medicaid, or Medicare, claims can still be submitted, but the doctor may not receive payment unless the patient has benefits that pay out-of-network.

The Insurance Credentialing Process

The credentialing process always starts with paperwork. This paperwork is 20 to 40 pages on average. Most insurance companies require hospital affiliation, a license, and malpractice insurance. They may also acquire information through the Council for Affordable Quality Healthcare profile. This is a database that has information on every practitioner. This alliance of trade associations and health plans is non-profit and works to simplify healthcare administration through collaboration in the industry. A completed profile places a physician a step ahead in the process, especially when getting credentialed by Medicaid.

Choosing A Practice

One of the areas that can interfere with credentialing and result in insurance credentialing rejection is when a doctor has to choose a practice. When a doctor joins a practice, he or she already knows what insurance companies they take, but that doesn’t mean the insurance company will accept additional practitioners at that location. At the start, this is an important aspect of deciding which insurance companies to become credentialed with.

If the office is not able to help, a credentialing company can. This can save a lot of time in applying and also save on rejections that can occur weeks or months after submitting the application.

Open and Closed Panels

Many times, panels can be closed, especially in cities where they may be a lot of doctors practicing in the same specialty within blocks of each other. Fortunately, there are ways to get around the rejections.

When a doctor retires or closes their location in one places, they tend to forget to inform the insurance companies that they are inactive, which prevents another doctor from being able to take over that location and receive credentials from the same insurance company. This means a telephone call needs to be made and the insurance company will then arrange a site visit to ensure that the location is closed.

Another way to get around rejection is to differentiate the practice from others. This means providing the insurer with the specifics, such as specialized equipment, certifications, and the specific experience of the patient. It also helps to integrate awards into these details because that could set the doctor apart and open up a spot on the panel.

Making the Practice Thrive

The question is whether or not a practice can thrive by taking on Medicaid, Medicare, and additional insurances. How many are too many?

It can be quite time consuming for a person in an office to submit applications for dozens of insurance, but an insurance credentialing company can help a great deal with this. It is practical to accept up to ten insurance companies, although there are approximately 60 out there today. You may want to apply for several additional companies in the case that acceptance doesn’t happen with the most favored companies.

Advocating for Your Approval

You can be an advocate for your approval and you can bring on the help of a credentialing company to help you. Unfortunately, credentialing is not always as easy as submitting a form, waiting a few weeks, and then being approved. The paperwork does have to be shepherded through and you may have to answer questions when the insurer wants additional information. There is also the fact that it has to be ensured that all information that is provided is correct, otherwise a rejection could happen. This is why the consideration of a service is recommended because it lessens the aggravation and allows all within the practice to focus on patients and the running office.

 

Insurance credentialing is not always an easy process, which is why MD Pro Solutions is there to help. Our credentialing service takes care of the legwork so you can concentrate more on your practice. To learn more, call us at 508-946-1665 or fill out our contact form.