Medical Credentialing: Equipping Yourself

For health care providers, medical credentialing is the process of getting networked with insurance companies (this is often described as “getting on insurance panels”).

Medical credentialing is a popular term among health care providers these days, especially among counselors, chiropractors, and even massage therapists who, only a few years ago, were able to run “cash only” practices. In contrast, today these providers are finding that patients and clients are demanding that they accept their insurance for payment. And if they don’t, then they’ll more than likely take their business elsewhere. Because they know they’ll be able to find another health care provider in their area who does accept their insurance. So, if you aren’t credentialed with major insurance companies, then you’re essentially turning clients away and the profit that they would bring you. Hence, if counselors don’t want to turn potential new patients away, they need to be credentialed with insurance companies.

Getting credentialed (or on insurance panels) involves retrieving and filling out a series of applications with insurance companies (which takes upward of 10 hours per panel), submitting the applications to insurance companies, ensuring each has received your application, and then doing a lot of follow up to track the progress of each application.

While it seems like there are only a few steps, which sound simple enough to complete, health providers often describe the process to be “nightmarish” as the application process rarely goes smoothly, and many providers find themselves resubmitting applications, fighting enrollment rejections, and spending a whole lot of time “on hold” with insurance companies. Additionally, many of the panels that you apply to may say that they are full or are not accepting people with your specialty at this time. It’s no secret that the process of medical credentialing isn’t something many health care providers look forward to—in fact, it’s a process that many health care providers dread.

While medical credentialing will probably never become your favorite pastime, there are a few things you can remember that will make the process easier:

1. Make a List

Research the insurance companies and find out which insurance companies you want to be credentialed with. Each company may require a different process with varying hoops you have to jump through.

2. Get Prepared, and Complete the CAQH

CAQH, the Council for Affordable Quality Healthcare, is often needed in conjunction with an insurance company’s application to complete one’s medical credentialing (i.e., to get on insurance panels). Major insurance companies, like BCBS and Aetna, use CAQH as a part of their application process.

There are a few important things you need to know about your CAQH application…

• You need to be invited. You can’t just go on to CAQH and upload your information; you need to be invited by an insurance company. This creates a near “Chicken or the egg” situation where you need to first submit an application to an insurance company. Then, call that company about two weeks later to see if they received the application and have generated you a CAQH number. Only then can you can go to CAQH, complete the application, which is –you guessed it–sent to the insurance company, who needs it to complete your application.
• Never opt to fill out your CAQH on paper. CAQH offers medical providers the option to complete the application online, or on paper. Don’t choose the paper option. First, the application is 50 pages long and only prints correctly in color. But second, and most importantly, when you submit a paper application to CAQH they need to hire some data entry person to transfer all your information. I’d like to say that they do a poor job–but the truth is…it just never gets done. I’ve submitted several applications to CAQH in paper before realizing they lose more of them then they input. When you call to ask what happened to your paper application, they simply recommend you complete your CAQH application online.
• Your resume better be perfect. One of the trickiest parts of getting a CAQH application completed that cuts the mustard is to make sure your resume is perfect. First, your dates of employment and education need to be in Month/Year format. If you don’t post dates, they reject your application and won’t send it on to the insurance companies. Secondly, make sure there are zero gaps in your employment history. Seriously, not a day–they’ll ask for something to fill the gap (hassle!).
• Don’t forget your re-attestation. Four times a year you’ll receive an email from CAQH, asking for you to “Re-attest” to the information in your profile. Not doing this can cause major problems with your ability to accept insurance, as the insurance companies you are paneled with will know the lapse in CAQH. Re-attestation only takes a few minutes (if you can remember your provider number and password), so log in and get it taken care of ASAP.

3. Expect to devote about 10 hours for every insurance panel you wish to be credentialed with.

Expecting that credentialing is going to involve just a few minutes of filling out an application will lead only to frustration. Instead, expect 10 hours of focused labor for each company you want to be credentialed with. This time will include retrieving applications, filling out applications, organizing necessary documentation, and following up with insurance companies by telephone. While some applications are electronic, the vast majority need to be printed and completed by hand.

4. Follow up with the insurance company often.

Insurance companies have a way of losing provider applications, or putting them in “limbo”–where they are not being reviewed properly and the medical credentialing process goes nowhere. The problem with credentialing application “limbo” is that if an application is stuck there for more than a few weeks, it might expire and be automatically rejected, leaving the provider (that’s you) with no option but to start again, from step one.

Hence, you will want to call each insurance company every time an application (or any documentation) is faxed, emailed, or mailed to them. After that, you will want to call every insurance company about every 2 weeks, to check up on the status on your credentialing applications.

5. Consider getting medical credentialing help

For many health professionals, it makes pragmatic sense to find a reputable service to help with medical credentialing. Not only does using a credentialing service alleviate the frustration and headache of the process (many providers have heard the ‘nightmare’ stories from their colleagues), using a service may also save money, and a reputable service will likely have better success getting you credentialed efficiently–meaning you can start seeing those clients with insurance sooner, rather than later. Also refer to https://credentialing.com for other details.

Some Commonly Asked Questions:

How long do I need to be licensed to get on insurance panels?

The answer can get complicated, as the rules change by insurance company, and by state. However, in most instances healthcare providers who are fully licensed (not intern-level or intermediate-level license) can get credentialed with most insurance panels. However, there are exceptions. UBH and United Healthcare like their providers to be practicing for a minimum of 2 years post licensure, and Value Options requires 3 year of post-license practice. On a positive note, in most states Blue Cross, Blue Shield, Aetna, Cigna, Humana, and many others have no post-licensure waiting period.

How long does provider credentialing take?

The credentialing process usually takes between 90-120 days, start to finish. Because of this, if you are getting ready to start a private practice, don’t wait until the week before you open your doors to start the process!

The insurance panels in my area are closed, what now?

While it is true that some insurance panels in some areas are closed, more often you find that they are more or less “restricted.”

What you can do is contact the insurance companies you are interested in working with and stress aspects of your practice that will make you more desirable to the insurance company. Perhaps you:

1. Work with children
2. Work with underserved populations
3. Are certified in hypnosis, EMDR, or some other niche form of therapy
4. Have extended office hours
5. Offer weekend appointments
6. Have a handicapped accessible office
7. Offer therapy in a second language
8. Have an affiliation with another practice or organization that is referring clients to you
9. Have a colleague who prescribed medication, who is willing to refer patients to you
10. Have some other specialty you can use to persuade difficult insurance companies to work with you

While no one’s success rate is perfect in situations like this, people are often surprised when they are able to get credentialed with insurance companies after they try these options.

Getting on insurance panels is not an easy process by any means, but with the proper preparation, materials, and persistence, you can become credentialed. With the changes in health reform coming in 2013 and 2014, make it your resolution to get credentialed.