Below are 5 factors that influence the insurance credentialing process for group practices.
The first key to provider enrollment is to choose the most appropriate insurance companies and panels to target. Not all insurance companies are created equal; in fact, deciding which companies to partner with is an essential first step for your group practice. Insurance credentialing takes up to 180 days and requires time-consuming preparation for each application.
The first key to successful credentialing is choosing which insurance companies will benefit your practice and your patients the most. When choosing the companies to partner with it is important to know which insurance is popular in your area and which insurances cover mental health services.
Some large insurance companies to research and choose from include:
The new influx of applications for insurance credentialing has led to many insurance companies reach patient capacity within the panels and closing to applications. While some panels may be marked ‘full’ or ‘closed’ an application can still be submitted. Often these companies are being more selective in regards to which practices they wish to add. Overcoming these closed panels requires determination on your part!
If an insurance company has a closed or full panel it is worthwhile to look into submitting an appeal to the company to discuss reasons why your practice should be accepted. These panels are often the most beneficial for your practice and your patients, so it is worth the extra effort to contact and communicate with companies who have stopped accepting open applications.
There are a handful of documents that will be required to supplement an application to an insurance company for credentialing. Each insurance company requires different documents for each practitioner, including a current resume or CV, signed W-9, state license, Face Sheet of Insurance, diplomas of education, certifications, record of disciplinary action (with explanations), blank/voided check, tax ID letter from the IRS, and a business license to name a few.
The organization of these documents is a critical component to the application. When applying, it is important to compile a similar list of documents (including other applicable licenses) and have them readily available upon request from the insurance companies for each practitioner. The more organized your documents are, the faster the insurance company can process your application.
Insurance credentialing can be a long process, but it is essential when starting a new practice or growing an established one. There are a variety of obstacles that may arise throughout the application process—so resiliency is your key to success. If your application needs a revamp, improve it, and then apply again. If you missed crucial documents, track them down, and apply again. If an insurance panel is closed, keep an eye for it to open, and then apply again. If an insurance company isn’t getting back to you, call them again.
Getting credentialed is a long process, but it will be a dead end if you aren’t persistent. Don’t get discouraged if the companies you want aren’t moving as quickly as you’d like. Keep applying and your resiliency will pay off when you finally get credentialed.
5. Time Management
The credentialing process doesn’t happen overnight. The timeframe for a single application’s acceptance is roughly 50-180 business days, and that’s if the application was submitted correctly the first time. Often appealing for a closed panel or reapplying with correct information can lengthen the timeframe to 230 business days. A single application takes roughly 8-10 manpower hours. Group practices should have a holistic understanding of the time required for insurance credentialing in terms of the application’s needs and the waiting period before acceptance.
Getting your practice credentialed by multiple insurance companies can often be a pain, but with proper planning and resilience your practice will be able to offer services to a multitude of insured patients. If the process seems a bit overwhelming, never fear! Our team is ready to help you make provider enrollment easy!
Payer Enrollment: It Pays To Outsource
Are payer enrollment requirements taking up more and more of your staff’s time? Are you burdened with payer enrollment tasks and follow-ups? Are you frustrated by the amount of time it takes to train your staff on provider enrollment and medical credentialing work and to keep up with the latest trends and requirements?
Outsourcing payer enrollment can make a big difference in the efficiency of your staff and the accuracy and timeliness of all provider enrollments and re-attestations.
Outsourcing provider enrollment responsibilities will benefit your practice by:
- Freeing up your staff for more practice and patient-focused duties
- Receiving quicker payment by insurance companies
- Relieving you from staying on top of new and changed requirements from CMS and CAQH
- Eliminating repeated follow-ups, phone calls, emails and faxes for submissions and re-submissions
With outsourced provider enrollment, you will receive expert support with no training required. A provider enrollment firm will complete all necessary credentialing requirements for each payer and follow through to completion.
Provider Enrollment – The Provider Enrollment Specialist’s difference.
At PES, our unique,state of the art software system and extensive experienced professionals makes our provider enrollment and medical credentialing processes extremely efficient.
Once your documents are loaded onto our database, our skilled specialists track applications, expiration dates and recredentialing needs for all insurance carriers as well as Medicare and Medicaid. We handle all applications and revalidations for you. Our integrated tools ensure that we do not drop the ball on any requirement or follow-up!
Our experienced team can handle any volume that you have.
Best of all, our services are extremely cost-effective. Using our provider enrollment and medical credentialing services will actually cost less than paying your full-time employees – plus benefits – to keep these requirements in top shape.
Remember – credentialing is our only business! We are the payor enrollment experts – let us go to work for you!
Let Us Manage All Your Payor Enrollment Services
If you require medical credentialing and payer enrollment needs for your practice or medical facility, please contact PES. Our experienced and dedicated specialists will provide all credentialing and enrollment services quickly and will monitor your account for ongoing updates and re-attestations
The first thing you want to do is to make sure you meet all the qualifications that you’ll need to get credentialed. There are a few steps to getting there, but don’t worry. Take it one step at a time.
Step 1: Check in with your state’s policies. You may need to be a licensed practitioner if that is something required by your state. You can see by this list whether or not this will apply to you.
Step 2: File as an LLC or S-Corp. If you haven’t gotten this far yet, don’t sweat it.
Step 3: Get Liability Insurance. This is a private practice must. There are many factors to consider when selecting an insurance provider, including amount of coverage, scope of services provided, type of coverage (e.g., in person, virtual care, or both), and more – the list goes on!
Step 4: Get your National Provider Identity (NPI). NPIs are a HIPAA protected way to identify you when filing an insurance claim. It is free to get an NPI and the application is relatively quick and easy. One of the biggest challenges seems to be finding your taxonomy number. (For Registered Dietitians, it’s 133V00000X. For Nutritionists, it’s 133N00000X.)
Now onto credentialing!
It may take awhile to get to this point, but don’t be deterred. You’re almost through. Nowadays, you don’t have to apply to every insurance company separately. It can be done with one easy and organized form through CAQH (Council for Affordable Quality Healthcare). This application is also free.
Before filling out this form, conduct a little bit of research to see what insurance companies you would like to become an in-network provider with. We recommend selecting a few – try not to put all your eggs in one basket!
The CAQH form will require your basic information. The website advises you gather all of this information together before you get started. It will ask for your basic information (name, address, contact, etc.), your education and training, specialties and board certifications, practice location information, hospital affiliation information, malpractice insurance information, work history and references, and disclosure and malpractice history. After you have filled out these forms, you will be asked which insurance companies you would like to share this information with. This is where your research comes in handy. Select the insurance companies and they will have access to your CAQH form and just like that, the credentialing process begins!
Now, just a few things to keep in mind: credentialing can take several months. It is a slow process. CAQH will contact you every 90 days to attest that the information you have provided in your form is still valid. You may want to consider following up with the insurance companies if you don’t think your form is being processed effectively.
Once you are credentialed by an insurance company, note that all companies offer different coverage. Some insurance companies will only cover a certain amount of sessions per year. It is always a good idea to familiarize yourself with what your insurance companies have agreed to cover.
Medical credentialing is a simple process, at least on paper. You send information about a provider’s qualifications – work history, education, certifications, licensure, and so on – to a payer for review and verification. After they go through a thorough vetting process, the payer confirms the provider and begins reimbursing him or her for services rendered.
In reality, it is not nearly that easy. In fact, according to the New England Journal of Medicine, the medical industry wastes about one BILLION dollars a year just due to the lack of standardization and coordination of administrative policies and procedures. That’s a large figure, and it speaks to the amount of waste tied up in supposedly simple administrative activities.
With that in mind, here are 10 common mistakes when it comes to credentialing and enrollment and how to avoid making them.
Not Allocating the Necessary Staff
Credentialing is a labor-intensive process. You need people to manage the workflow, enter the data, fact-check the reporting, and the list goes on. Not having the appropriate allocation of staff can lead to mistakes, which will lead to delays, which will ultimately impact your revenue.
Avoiding this mistake boils down to not underestimate the amount of work credentialing at your practice requires. Dedicate a resource to submitting, monitoring, and maintaining provider credentials with your payers, centralize the credentialing function for your organization if you have multiple locations or lots of providers, or outsource your credentialing workflow to industry experts who can spare the resources to manage it.
Not Challenging Delays
Even if everything is 100% accurate, you will still experience delays from payers due to their backlog of applications. Challenge these delays. Confirm with your payers that your applications are received, follow up to ask for a status, and even provide copies of FedEx and/or email receipts. As the saying goes, the squeaky wheels get the grease. By staying on top of your payers, you can ensure that the process moves forward as quickly as it can.
Letting CAQH Lapse
CAQH profiles need to be re-attested, updated, and the credentialing contacts kept current. By being proactive and updating CAQH right when you receive an updated insurance, license, or DEA document, you can avoid delays.
Not Creating a Sustainable Process
Develop policies and procedures to help manage your credentialing process. They should address the “who, what, when, and where” of commercial and government payer credentialing.
For example, you may want to require providers to maintain a current profile in the CAQH database. Since it houses most of the information needed for credentialing, if a physician keeps his or her profile up to date, then the person responsible for credentialing can access information from one central location, limiting the need to hunt down items from various sources. Make sure your process is clearly understood by staff and repeatable every time credentials need updating.
Failing to Build Relationships
Strong relationships with payers and plans are key. That way if there are problems or issues with a provider’s application, you can pick up the phone and resolve them in real time, instead of waiting for a letter or, even worse, receiving no communication at all.
Good relationships can also allow an organization to be more proactive. Having a strong rapport can be helpful on many levels. If you have a good relationship, the rep might give you a heads up when things are changing so you know ahead of time instead of after sending in all the information.
Not Knowing How Plans Work
Commercial plans are different payer-to-payer and state-by-state, and what may work for one may result in delays for another. Understand the individual requirements and nuances for each of the plans you work with and the regulations for your state – particularly when it comes to timely credentialing laws – to avoid problems.
Sending Incomplete Applications
One of the most common mistakes associated with credentialing is a lack of attention to detail. Application errors lead to delays and potentially denials. A typical credentialing application will ask for practice address, phone, fax, contact information, services provided, copies of your licensure, employment history, average patient profile and any records of past legal troubles regarding your medical practice.
Starting Too Late
Many practices get started too late, which can be a matter of success and failure for your practice. At a minimum, you want to give yourself at least 90 days. Realize that you are working on someone else’s timeline – your payer’s.
The responsiveness of the payer to your application will be determined by their workload and their motivation to add new providers to their network. In short, the process is probably going to take longer than you think, so build in extra time and get started early.
Not Following Up
Even if you are not experiencing a delay, still make every effort to contact your payers and follow up on the process. Once again, squeaky wheels get the grease. It is to your benefit to stay in front of your payers and ensure that they are processing your applications. Make follow-up a routine and stick to it until the application is approved and participation is secured.
Not Seeing the Big (RCM) Picture
Credentialing and enrollment are the starting point for your practice’s whole revenue cycle. A weak credentialing effort can have serious financial ramifications for your practice. The price you pay is lost revenue, unhappy patients, delayed payments, out-of-network services, and denials, combined with coverage and referral issues. It is important that you do not lose sight of the revenue cycle during this process.
Credentialing can be frustrating and cumbersome, but, by providing it the attention that it deserves and understanding that it is the foundation upon which your revenue cycle is built, you can minimize the common mistakes that ultimately cost your practice money.
Provider Enrollment Specialists, LLC is focused on provider enrollment or insurance credentialing and everything else that goes along with it.
Provider Enrollment Specialists are experts with plans out of Northern Michigan but we have worked with plans all over the United States. We consist of a team of two professionals with combined 20 years experience in insurance enrollment, insurance contracting, provider credentialing, and Medicare enrollment. PES has the talent and tools to move you through the process of insurance enrollment without the headaches typically associated with this process.
The credentialing process is a tedious process, regardless of who’s doing it, which is why it is so important to have experienced partners at your side. Please select the following areas you are requesting our assistance: Let us handle the headache of paperwork!
- Medicare or Medicaid Enrollment
- Physician Enrollment
- CAQH Enrollment
- PECOS Enrollment
- Government health plan enrollment
- Obtain NPI and maintenance
- Behavioral Health, Dental, Medical and Pharmacy Insurance Credentialing
- Nurse Practitioner Credentialing
- Physician Credentialing
- Facility Credentialing
Do you really want to keep your credentialing in house but aren’t sure how to handle it internally? Let us show you. Our dedicated professionals can train in house for 1 week on all insurance credentialing processes and then we are available 90 days remotely for any and all questions along the way. We have traveled all over the US, helping companies just like yours keep their information in house. Consult with us to show you the process to getting on insurance panels. Consulting packages range from $5,000-$10,000 and is only a one time fee! See what our happy clients are saying about this amazing alternative to outsourcing.
Credentialing packages start at $75. We try to build a contract around your specific needs and budget.
We believe your focus should be your patients, not on credentialing paperwork. Our contracting and credentialing services are affordable, reliable and save both time and money. Why take a chance on such an important part of your practice, our experts are ready to assist you today! Click here to view what it will cost you for peace of mind.
As we all know, healthcare facilities exist to facilitate and administer medical care to their patients. While we have advanced like never before in our cure rates, infection prevention, disease management, OR efficiency and nearly every other available metric, the roadblocks to actually running a successful practice have done nothing but increase in size.
Every practice, regardless of its size, is faced with a daily barrage of challenges that aim to prevent or limit the practice’s payment for services. Within the revenue cycle, physician credentialing and insurance enrollment represent the first obstacle in obtaining timely payments and is what we’d like to cover in this article. As you likely know, insurance credentialing or provider enrollment has evolved over the years to be one of the most complicated and confusing processes within any industry. In this article, we’ll review three reasons why outsourcing your credentialing and enrollment department could make your revenue cycle more efficient and your practice more profitable.
Reduced Labor Costs
This is pretty self explanatory and we challenge you to take a close look at what the credentialing and enrollment process is actually costing your organization. In all likelihood, the person tasked with handling your insurance enrollment and credentialing also has a number of other responsibilities within the organization. Unfortunately, these other responsibilities (while they may be important) typically supplant enrollment and credentialing needs as the top priority. With declining reimbursements and rising costs, most practices are forcing more and more on their limited number of employees. While we agree with watching labor costs and distributing work across the practice, it’s critical that certain compliance and credentialing requirements remain at the top of your staff’s to-do list. If you look closely, you will very likely find that your current staff’s workload is unsustainable and is resulting in unnecessary overtime and errors. By outsourcing to a professional organization, you not only reduce the stress level on your current staff but also ensure the top priorities of your organization do not get shuffled to the bottom of the stack. One error or misstep within the credentialing process could literally bankrupt your practice. We have seen it happen numerous times over the years. Whether it’s a Medicare revalidation ignored resulting in the deactivation of PTANs or re credentialing requests that are tossed and result in termed contracts, you don’t need this added liability.
Efficiency is key within every industry and healthcare is no exception. If you’ve been running a practice for any length of time, you know that the credentialing and enrollment process often feels like you’re walking in a maze with a blindfold on. Credentialing professionals get out of this maze by relying on advanced technology and payer relationships. An example of this would be a professional credentialing organization’s ability to bypass the 800 number of a provider enrollment department and go directly to a regional network manager. The relationship that bypasses the customer service department usually results in at least 30 days shaved off of the entire credentialing process. In addition to the relationships, advanced technology utilized by professional credentialing agencies ensures the accurate and timely submission of all applications and forms. It also ensures that the correct forms are used and delivered to the correct address, fax number or email.
Eliminate Risk of Turnover
Turnover happens, regardless of how amazing your organization is. When it occurs, it usually happens at the worst possible time, not when you can afford to lose someone. How will your organization be affected by turnover in your RCM or credentialing department? Our company is no exception and has had to deal with turnover in the past ten years. The difference is in our ability to effectively deal with turnover through our commitment to cross training and disciplined project accountability/tracking. These commitments ensure that management is never left in the dark regarding the status of an account and anyone, at any moment can pick up where someone else left off.
In summary, outsourcing credentialing and provider enrollment is the equivalent of a primary care physician referring to a cardiologist when a patient presents with an irregular heartbeat. While the primary care physician could very likely handle the problem internally, is the risk of missing something really worth it? That’s really what you must ask yourself. Rather than watching credentialing needs be displaced to the bottom of the stack, or being done incorrectly by someone who lacks proper training or experience, why not outsource to a professional organization? Based on national credentialing surveys, the average time for a physician to be credentialed by a group is 180 days. We can say that there are only a handful of payers across the country that ever take us more than 4 months to complete. Is finishing the process faster and more accurately important to you? If it is, we believe you’ll reach the logical conclusion that outsourcing is the answer.
- Save you on average at least 2 months of time and over 100 or more hours of work!
- Take away all the headaches due to the mounds of paperwork and endless applications!
- Increased patient referrals!
- Get you paid by the insurance companies faster!
- Contracts and applications are setup right the first time and we will not stop until the process is 100% completed!
- Dedicated project manager assigned to your project!
- We make all the phone calls, follow-ups, and submit all applications, e-mails and faxes for you!
- The service is typically provided at a cost less than it would be for you to hire your own provider enrollment or credentialing team and we can handle any volume you have!