Insurance Credentialing For New Healthcare Practices


Time and again new practices invest countless hours and money focused on office space, equipment, software and staffing only to open their doors for business and find significant delays in obtaining adequate insurance reimbursements. More often than not, the problem could've been allayed by addressing the insurance credentialing process early and thoroughly – creating the necessary relationships with insurance carriers. Here are a few considerations to keep in mind as you address the insurance credentialing process.

Timing – Start Early!

Plan on starting the insurance credentialing process early – at minimum allow at least six months before you see your first patient. Carriers will often take as much as 3-4 months to review documents and make a determination, even if everything is in order. If there are errors, missing information or a question about submitted documentation, several more weeks or even months can be added to the process. This six month allowance, starting from the time credentials are submitted, usually gives enough time to address problems should they arise. If too little time is granted before the practice opens, and you begin seeing patients before insurance is complete, you are open to the risk of getting an "out of network" rate, reimbursements may be sent to the patient, or, worst case scenario, you may not get paid at all.

Identify Target Carriers

To define which insurances you may credential with, consider your practice location and patient demographics. Will a significant percentage have Medicare or Medicaid? Is there a particular company or business in the area that employs a large portion of the surrounding population? A quick call to their human resources office to inquire what insurances they are currently offering employees (as well as possible changes the near future) can be a good indicator of the carriers you'll want to consider.

Also, check with colleges, other providers, clinics and even larger hospitals in the area and ask who their most common payors are. Inquire about which payers are best to work with – who reimburses in a timely manner, which offer the largest enrollments, and which carriers might be at capacity with other providers in your specialty.

As you identify which insurance carriers might be most popular in the area, make a list of the top 10 or 15. This will be your short list of where to go next. Do not go overboard and choose too many from the start – if nothing else, you'll run yourself ragged in keeping up with the submissions.

Contact Insurance Carriers

With your list of 7 or 8, prepare to spend at least an afternoon (or more) on the phone with the provider services offices of each of your target carriers.

One of your first questions might be to ask if they are accepting new practices in your specialty in your area. More often than not there's no problem here, but do not be discouraged if they say no – just keep moving down the list and prepare to check back with them later for an opening. (Just remember, if several carriers on your list indicate that they are closed to new providers, you might want to reassess your location before moving forward – finding multiple carriers closed to new practices in the same area is a strong indicator that there's a lot of competition in the neighborhood.)

If the carrier is receptive to new providers, make sure you get all relevant information about the process – ie names, addresses, phone numbers, timing, required forms, and so on. Do not forget to ask about online submission too, as many carriers today allow you to provide all information online and mail in the supporting documentation.

** Remember that carriers will not start the insurance credentialing process until you've established a practice phone number and address (a PO Boxes are not acceptable). If you've established a practice address but have not moved in yet, carriers can typically send the forms to an alternate address, but you'll still have to identify the location to get things going.

Submitting Credentials

Now that you've completed your research and identified which insurance carriers you're going to file with, you'll need to compile and submit all of your information. Most will generally require you to provide the following:

  • Updated resume
  • Personal demographic information
  • Practice and business information
  • State and federal DEA numbers
  • State licensing and registration information
  • Evidence of education – ie Diploma or ECFMG certificate
  • Malpractice insurance information
  • Information on any diplomatic actions
  • While this can be a lot, there is some good news – since most carriers ask for the same information, once the first submission is complete, you can just transcribe all the details from one form to the next. You will also benefit enormously in the future by storing copies of these documents in a safe place. As your practice matures and you seek to credential with other insurances, you'll have this same repository of information readily available.

    Once you've completed the application, do not forget to double check everything. In fact triple check it and have someone else look over it as well. Do not expect carriers to correct an obvious mistake for you – it's not their responsibility, and, frankly, they just will not. The importance of double and triple checking can not be stressed enough as the entire process can be help up by a month or more from the slightest mistake.

    Finally, after your information has been submitted, allow an appropriate amount of time (1-2 weeks for miled submissions) and follow up with the provider services office to confirm receipt. If you were able to obtain a contact name in your early research call them directly. Once receipt is confirmed do not hesitate to follow up again in say, 3-4 weeks to see if they've reviewed it yet or if they found any problems. If everything's on track, plan on checking back in another 3-4 weeks until the process is complete. This can save a lot of turnaround time if you can learn over the phone there was some sort of hold up. As alluded to above, expect this part of the process to take several months – crediting offices are often centralized and may be reviewing hundreds of submissions for many different areas at any given time. If there's no movement after several months, you consider stepping up your calls to a weekly basis.

    Hopefully your hard work and phone calls has paid off and you've made it through the insurance credentialing process in just a few short months with your original list of 7 or 8 carriers. If you're up for the challenge yet again, consider going back to your longer list of 10-15 and start the process all over again with the remaining carriers.

    A few shortcuts

    Here are a couple of shortcuts to credentialing not mentioned above.

    Hire professional assistance: There are many different organizations that can help with the insurance credentialing process. If you've contracted with a practice management company this process is often covered already. If you're considering a medical billing company to manage your insurance and patient billing they certainly should have the experience with carriers to provide at least some guidance, if not manage the process for you. Also, there are a few professional insurance credentialing companies that specialize in this process for new practices but they can often come at a high price.

    Universal Credentialing DataSource: The Council for Affordable Quality Healthcare has developed an online service intended to eliminate the need for multiple insurance credentialing submissions. In short, you complete one form for all of their participating insurance carriers and you authorize who will receive your information. The CAQH Universal Credentialing DataSource is located at:


    The insurance credentialing process is critical to getting your practice off to a good start – and ensuring a quicker transition to profitability. While it can be time consuming, an early start will give you the chance to address problems should they arise. Just be patient and keep these tips in mind and you'll get through it:

  • Start early – expect the process to take up to 6 months
  • Choose a target list – do not try for every carrier out there
  • Double check your work before you send it in
  • Follow up regularly and keep the process moving
  • Do not be overwhelmed – it's just paperwork.
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    Source by K Allen

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