Just a couple of decades ago getting credentialed with an insurance panel wasn't so critical to a practice's success. Patients didn't expect that every doctor would accept their insurance, not every service was covered by insurance (such as- chiropractic care, mental health, and substance abuse), and most insurance plans offered some out-of-network benefits so you could grow your practice even without enrolling in every plan.
Needless to say, times have certainly changed. Now it is essential for every doctor and even non-physician providers to be "in network" if they want a thriving practice. More people have health insurance and more health insurance companies require provider credentialing than ever before, meaning the non-credentialed provider has very few options for revenue.
That said, the credentialing process is anything but easy. Here are some pitfalls to watch for and ways a medical billing company is better equipped to manage them.
The new provider is coming from another state
Most states do have their own laws regarding credentialing periods and in-state and out-of-state procedures. Fortunately, many states have reciprocity agreements, allowing an expedited credentialing process for providers who were credentialed in one state moving into another. Unfortunately, however, few practices have the internal manpower to untangle and understand the laws and policies of every state.
A medical billing company, however, usually has clients in multiple states, and a credentialing staff that understands the regulations and reciprocity shortcuts for each. This means they won't waste valuable time duplicating effort unnecessarily.
The insurance panel is full or closed
This is becoming a more common occurrence as provider networks fill up, especially in competitive markets, and insurance companies place barriers to entry for doctors and other health care providers. In many cases, however, "closed" is simply a euphemism for networks being increasingly selective about whom they let in.
A medical billing company, which handles credentialing for hundreds or even thousands of physicians each year, and works with all the major payers in a given geographic area, is better equipped to know what a network is looking for and can better highlight your provider's experience, specialty credentials, or even promote services in an under-served area in order to get him or her credentialed with an otherwise closed network.
Related Article: Understanding the Importance of Provider Credentialing
The provider is a new medical specialty for us
This is a common problem for practices aiming to broaden their patient mix and expand their services. A family practice group may add a behavioral health clinician, for example, or an orthopedics group brings on a physical therapist. The credentialing process for non-physician providers is usually different from that of MDs with most insurance companies, and it can be confusing and time consuming for an individual practice to navigate the process.
Medical billing companies typically have experience credentialing every type of health care professional, since they work with a broad spectrum of medical specialties and clinics. Your new specialist or NPP is nothing new for a billing company, so there is no learning curve and the process is smoother for everyone. They're prepared for the unique documentation and certification requirements.
Of course, these are just a few of the more common hiccups for practice administrators in the physician credentialing process, and there are many others that may come up. Just remember these tips:
- Start early; give yourself at least 120-150 days to complete the process.
- Insist that providers update and attest their CAQH profiles on a regular basis.
- Develop a master file and checklist so you can easily track progress and find necessary documents.
Have questions or concerns about the provider credentialing process in your practice? Let the M-Scribe RCM experts help you avoid pitfalls in the provider credentialing. Contact us today for a free, no obligation consultation.