Private Practice and Insurance Credentialing

Healthcare providers trying out into private practice often are unsure about establishing their procedures for third-party billing networks for services. The process of billing and reimbursement sometimes refers to as the “Revenue Cycle.” The first step in the revenue cycle is to obtain credentialing and a participating provider contract with insurance companies important to your service area. Building a successful revenue cycle for a new practice can be a complicated matter. Still, with a bit of planning, you can make the process seem a bit less intimidating. Here are some of the critical steps in the process to provide you with a little bit of guidance in setting up the revenue cycle for your new private practice.

Prepare for Credentialing

Credentialing is a process that insurance companies use to verify your education, training, and professional experience. Ensure that you meet their internal requirements to serve as an in-network provider on their panel. Insurance companies are required to provide web-based provider directories listing all in-network providers for their plans. Healthcare service consumers regularly use these online directories to locate physicians and other healthcare providers who accept their insurance. The first step in implementing your new revenue cycle is to get credentialed and contracted with the insurance plans that are important to your service area. Once complete, consumers will be able to locate you as a participating provider in their panel for your specific specialty.

The process of “credentialing” or “provider enrollment” with an insurance network consists of two phases.

1) Credentialing and 2) Contracting. The credentialing phase is when the insurance company verifies all your credentials and meets their requirements for participating in their network. The contracting phase is where the company issues you a participating provider agreement that defines the terms of participation for receiving in-network reimbursement for your claims.

Without a participating provider agreement, you will not receive in-network reimbursement. Until your credentialing and contracting are complete, you may have the option to bill the network as an out-of-network provider. Still, there is no guarantee that your claim to process. Whether or not your claim is even accepted depends on if the patient’s policy has out-of-network benefits. Government health plans such as Medicare and Medicaid will not pay for any out-of-network services.

Which Insurance Companies Should I Credential With?

Consider asking a peer in practice in your area or an office manager who handles billing in your area what insurance companies provide the most patient base. That practical knowledge about local insurance companies can be a valuable major. National plans to consider including Aetna, Blue Cross Blue Shield, Cigna, United Healthcare, Humana, Medicare, and Medicaid. There are many Medicare Advantage plans as well as managed Medicaid plans for consideration as well. Some major national PPO plans rent their network, such as Multiplan that can be important in certain areas.

Checklist items for credentialing and contracting preparation:

Checklist for beginning the process

Upon Completion

Billing In-network

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