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Credentialing: 8 Factors to Consider

So you are ready to build a private practice AND you want to accept health insurance. Well, the choice to accept insurance is just the first step. Knowing that not all insurance companies are created equal means you will have to consider which insurances you will accept? When you are deciding there are a few things you may want to consider.

Client Volume…Find them in Droves

It certainly makes sense to accept an insurance that gives you a large volume of clients. Do a bit of research to discover what insurance companies are popular in your area. Nothing too complex, just note the insurance that is offered by the State Government or the School System and also look into a few big companies or hospitals. Go by what you know.

Open Panels…Open for Business

There will be some insurance companies with closed insurance panels. Most often that is based on the ratio of clients to providers in the area. Other times an insurance company will have a model where all services are provided by in house providers that are direct employees and they won’t open to outside practitioners.

It is also helpful to bear in mind that even for a panel that is accepting new providers, they may have rules about who they will accept that might present a barrier. Some companies require that new providers have spent two years practicing with advanced licensure before they let you join. Perhaps they read my Let the Ink Dry blog!

So bear these things in mind if the insurance you are interested in accepting is not open now…they may open back up in the future. Be encouraged, take your time and the panels will begin to open for you.

Planning for Timelines…Wait for it

Joining panels can be a lengthy process. They will always share the length of time estimated for the completion of your application. Some panels like Medical Assistance will provide a same day answer and others like APS Healthcare can be up to 180 days. Do yourself a favor and develop a spreadsheet to track your efforts so you know when to follow up.

Fee Schedules—How much exactly

This one is very important. The fee schedule is the disclosure that lets you know how much you will be paid for your services. It usually looks like a chart that shows the reimbursement for each code based on provider type. For my clients, I have a practice budget spreadsheet that we use to plan for fiscal matters. Without fee schedule information, you cannot accurately plan for revenues.

Online Directories…Can you find me

Insurance companies that have an online directory make it so much easier for clients to find you. Lets face it, accepting insurance can serve as a marketing strategy for a new practice. Choosing companies that allow you to customize a profile so your clients can learn about who you are and what you do is a real benefit. The goal here is to maximize your visibility to potential clients.

Authorizations Required…Ask First

Although many insurance companies have moved away from requiring pre-authorization for services there are some that still do. Find out if an insurance company requires pre-authorization or a referral in order for claims to be paid. This may vary based on a the policy that an individual has, but you can see how prevalent it is based visiting an insurance company’s website and researching the instructions they provide for the clients covered by their plans.

Electronic Billing and Reimbursement…Automation at its Best

Being set up for electronic billing and payments makes life a lot easier for you and your biller (if you have one). One of the complications of dealing with insurance is tracking claims to make sure they are paid. If you have an electronic billing system set up, submitting claims goes smoother and you can have payments deposited directly into your business banking account. That my friends in automation at its best!

Timely Filing Procedures…Move Fast

Timely filing are the rules around how much time you have to submit your claim after you provide services. Some companies have fairly short windows of when a claim must be submitted. Learn about what path leads to the denial of a claim BEFORE you get in bed with an insurance company and then build your office policies and procedures to maximize good results.

Last but not least

Once you have made your choices and are ready to get started, you might have questions about where to look to join. When visiting websites for the insurance companies, you will be looking for areas with titles like, “Provider Enrollment”, “Credentialing” or “Join our Network”. There you will find all the information you need to get started.

Let me know if you have any other questions about choosing which insurance companies to work with. I would love to see you get off to a strong start. Take good care of yourself and Let’s Grow!!!

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