Healthcare providers venturing out into private practice often are unsure about establishing their procedures for third-party billing networks for services. The process of billing and reimbursement refers also called 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 Private Practice & Insurance Billing is complicated, but you can make the process a bit less intimidating with a bit of planning. Here are some reminders to keep you in the loop. 

Prepare for Credentialing

Credentialing is a process that the insurance companies use to verify your education, training, and professional experience and 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. These online directories are regularly used by healthcare services consumers to locate physicians and other healthcare providers who accept their insurance. Therefore, 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, but there is no guarantee of your claim being processed. 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.

Checklist items for credentialing and contracting preparation:

  • Consider establishing a business entity under which to practice (LLC, S-Corp, PC, etc.) and obtain your tax ID
  • If operating as a sole proprietor, consider bringing a federal tax ID to operate under instead of your SSN
  • Obtain your professional liability insurance policy
  • Obtain an NPI number for you individually (type 1) and your business entity (type 2)
  • Be fully licensed in the state where you will provide services (including prescriptive authority)
  • Create a profile with CAQH and keep it current
  • Have your practice location ready
  • Know which insurance networks you want to participate with

Credentialing With Insurance Networks

The process is time-consuming. Once you have prepared for the process and know which insurance companies you want to participate with, it’s time to get started. Expect to spend anywhere from 2 – 6 hours on each application when considering application preparation and follow-up throughout the entire process. In many instances, it will make economic sense to outsource this critical revenue cycle step while you focus on treating patients or work on other business-building activities.

Many physicians and other healthcare practitioners starting a new practice who previously worked for another organization often think that since they are already in-network with an insurance company, little or nothing needs to be done for their new private practice. However, in many situations, those providers participated under the previous organization’s group contract, which will not transfer to the new private practice. Do not assume in these situations that your credentialing process will be any faster with the insurance companies. Contact each plan to determine your contract status and get instructions on setting up your new practice. Some will require you to go through the entire process from the beginning; others may have abbreviated processes to get a new private practice contract issued. If you participated with the previous organization under an individual contract, you might transfer your contract to your new private practice. The process varies widely by plan.

Checklist for beginning the process

  • Contact the network provider services department to inquire about their credentialing process and obtain a credentialing application. Most plans have applications and information on their website, such as here with Aetna.
  • Take time to fully complete your application listing all service locations for your practice, sign and date your application, and include copies of all required documents.
  • Ensure that your CAQH profile is up to date with all information, mainly practice location information, and includes copies of all required documents such as license, insurance, board certifications, etc
  • Retain a copy of your completed and submitted application.
  • Verify with the insurance company that your credentialing application was received, and follow up with the insurance network regularly until your credentialing is complete and you have an effective network date with a participating provider agreement
  • Respond to any requests for additional information that the insurance company may have
  • Document all of your follow-up activities as you go through the credentialing process.
  • Review your participating provider contract for details of your requirements as a network provider, claims submission procedures, fee schedule for your services, timely filing limits, and other essential contract terms.
  • Keep copies of all credentialing applications and contracts submitted. Be sure to retain a final copy of your network contract.

Upon Completion

When your credentialing process is complete, you are ready to begin billing the network for services. Here are a few key things to remember about maintaining your credentials:

  • Access the network website so that you can confirm you are listed in their directory. Most networks also have access to claims filing, benefits verification, claims follow-up, and other revenue cycle activities on their website.
  • Record all contact information for the insurance company related to claims filing, contracting, and credentialing.
  • Record your provider id, effective date, and when your following re-credentialing process will be due
  • Maintain copies of all your network contacts in one central location for ease of management
  • After a year of service, evaluate which networks provide patient volume and compare reimbursements to identify carriers to eliminate or renegotiate reimbursement rates.
  • Maintain your CAQH profile by quarterly attestations and document updates any time you renew an item such as license or malpractice insurance
  • Maintain your NPPES records so that your NPI numbers always reflect the accurate name, address, and other information
  • Do not neglect re-credentialing requests from plans or requests for renewed or additional documents. Failing to respond to a request can lead to a network termination.

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