Credentialing Facts

In order to take or accept insurance from your patients, you must be credentialed with insurance companies. The act of credentialing can be a long and tedious process. Credentialing entails a lot of energy from you and the person who is credentialing you.

Here are five things you will want to think about when attempting to credential yourself or a staff ‘members’:

Network Closure

Before a credentialing agency takes your information, the first thing they will ask is what insurance panels are you wishing to be a part of. Once that is determined the credentialing agency should contact the insurance companies of your choice to see if they are still taking health care providers at this time in your area. Depending on the saturation of providers, you may not be able to get into all of your preferred networks until the insurance company opens again.

If this happens you have two choices.

1. You could apply anyway and state your case on why you should be in their network or
2. Find a provider that is already in-network and join their group.  (which would result in working for another provider).

Paperwork

Legitimate providers who credential providers have a preliminary form that must be filled out. 

Some of the items that must be sent to the credentialing company are as follows:

• Provider Enrollment Application
• State License
• DEA License
• Board Certification
• Education and Training
• Hospital Affiliation
• Malpractice Insurance Certificate

All of this information must be given in order to get started to fill out the application. You cannot move forward if all of these items are not given to the credentialing staff.

CAQH Must be up to date

CAQH is a universal provider data source. This database is where providers put most or all of the documents you see above into in order to have all documents in the same place. This is a key way for providers to get credentialed fast.

If your CAQH is not complete this is one more task that the credentialing service will charge for in order to obtain the insurance panels of your choice.

Expected Time Wait

Once everything is done it is imperative to wait and have patience. For example for commercial carriers which are BCBS, United Health Care, and Aetna to name a few it usually takes a total of 90 – 120 days from the time an insurance company receives the providers credentialing application to the time they receive the final contract. For Medicaid and Medicare these panels take the longest about 120 days or more due to the detailed screening and fingerprinting required. 

Your credentialing agency should check on your applications every two weeks. They should report to you the reference number for the call or contact and alert you if there is any change in status.

Email and Mail

I cannot stress how important this is. It is important to check your mailbox regularly. I suggest at least every 2 days and here’s a story that explains why I stressed with a client they had to check their office mail at least every two days. I know this is tedious but if an insurance company wants more information they can reach you many ways. Even though I placed my name as the contact with the email, fax, phone and office mail they did not contact me they contacted my client. My client did not check their mail for over two weeks. A document was sent to them requesting hospital admitting privileges with 48-hour turn around. Since the date was missed we had to start the application process again. So please check your email and mail on a regular basis.

Credentialing can be stressful, time-consuming and downright a hurry up and wait situation. But this is needed in order for your practice to take clients that are in need of your services. Turning people away because you do not take insurance should not be a reason. Each person you turn away is a person that could have brought revenue to your practice.

By Courtney Harring