Credentialing Corner

# How to Credential A Provider With Insurance Companies

- September 19, 2024
- Posted by Brian Bertrand

19 Sep

At the time, patients were receiving medical services on a cash basis. However, with insurance companies’ introduction of insurance plans, patients want doctors to accept payment from their insurance. If a healthcare provider does not do so, they will move towards another provider who agrees with the insurance payment.

For that specific reason, healthcare providers must get credentialed with the insurance companies that cover patients’ medical bills. They can get reimbursement for their rendered services from third parties known as insurance companies. Provider credentialing is a crucial and complex process that should be done accurately before billing insurance companies.

This article will elaborate how to credential a provider with insurance companies. We will discuss key steps and importance of provider credentialing as well.

# What is provider credentialing?

Provider credentialing is the process of evaluating the providers’ credentials, including medical degrees, training certificates, work history, and licenses. This process helps to know whether the provider holds all the necessary requirements to meet the standard of providing healthcare to patients and receiving reimbursement for those services.

Through credentialing, healthcare providers are recognized and appear on the list of credentialed providers. Patients find the relevant healthcare practitioner under their insurance plans from the list. If you are on the list, patients will come to you for medical services, and your business will grow.

## How do I get credentialed with insurance companies?

Many steps should be followed in order to get credentialed by insurance companies. There are two main phases in this process, i.e. credentialing and contracting. First, you get credentialed and then negotiate a contract with the company to provide services to their insurance-covered patients. The following are steps to get credentialed:

### 1. Research preferred insurance in your area

Only some insurance companies are working in some areas. Each area has specific companies covering most of the patients’ insurance plans. You need to find the insurance companies typically used by the people. You will go to get credentialed with only selected companies. It is not recommended to have a credential with every company.

### 2. Gather required credentials

Before starting the process, it is necessary to know the companies’ credentialing requirements and gather all necessary documents to make the process smooth and efficient. The following is the checklist for provider credentialing.

- Current state medical license
- DEA certificate (if applicable)
- Board certification
- Curriculum Vitae (CV)
- Malpractice insurance coverage
- Hospital privileges (if applicable)
- NPI (National Provider Identifier) number
- Professional references

### 3. Obtain a CAQH profile.

The Council for Affordable Quality Healthcare (CAQH) is an online portal that all insurance companies use to get providers’ information. For credentialing with insurance companies, it is recommended that you make a profile on the CAQH portal and update the latest information with time. You just need to go to the CAQH website, fill in all necessary information, including your NPI number, and submit the information. You need to submit all credentials along with the proof of legitimacy.

The CAQH portal is a permanent source of provider information. Anyone with a provider ID can access the provider’s profile and see the information he seeks. A provider should update all the latest information on his profile and provide proof of each piece of information.

### 4. Apply to insurance companies.

This is the most crucial step and should be done carefully. Providers need to apply for credentials from companies individually. Each insurance company has its own rules and requirements. You need to submit the application to the insurance companies along with all necessary documents.

Some companies ask the provider just to submit an application with CAQH ID. They obtain providers’ information through the CAQH portal. On the other hand, some companies ask the providers to submit all information to their website. They do not use the CAQH website. They verify all data by themselves.

### 5. Follow-up on application

Once you submit the application, it is necessary to remain updated with the status of the application. In case of any missed or wrong information, you need to sort the problem out as soon as possible to make the process effective. Insurance companies verify your data using third parties or through primary source verification.

### 6. Negotiating contract

How to get contracts with insurance companies? It is only possible if your application is approved by the company then, you move towards the second phase which is contracting. After application approval, providers sign a participation contract and also negotiate the rates for the medical services he will provide to patients.

Terms and conditions about the reimbursement rates, billing procedures, pre-authorization requirements, appeals process for denied claims are decided and the final contract is signed. Both parties abide by the contract and providers get reimbursement from the insurance companies.

## What after credentialing with insurance companies?

After getting credentialed with insurance companies, you sign a contract to decide different things. You can start practising medicine and billing companies for all the services rendered. One thing that is really important in business is audit and compliance with policy rules.

Healthcare providers need to maintain their standards for healthcare as they are audited by the insurance companies. In case of any irregularity or negligence in protocols, their contract can be terminated and they can face tremendous business loss. For coping with this situation, providers should have licenses and certifications up-to-date, maintain patients records and perform billing documentations.

## Common challenges in provider credentialing

There are some challenges in this process and solutions should be found to resolve challenges and make the process smooth. There are many roadblocks for the new providers who wish to be credentialed and practice medicine as there are many insurance companies who sign contracts only with experienced providers. They ask for about 6-12 months of experience before accepting credentialing applications. It is not true for all companies.

Another hindrance is varied requirements for credentialing by different insurance companies. You have less time to gather all documents to submit and in case, you miss some document then, the application gets rejected. Once you submit an application, some companies give you just 6-10 hours duration to fulfil their requirements, making it difficult to meet all protocols in a short duration.

Saturation is another red flag in the whole scenario. Due to saturation of medical providers, many insurance companies accept limited applications for credentialing making the process more difficult. Saturation can also lead to long processing time which affects the business of healthcare providers.

## Conclusion

Credentialing with insurance is a very crucial but important process. Every healthcare provider needs to get credentialed to receive reimbursement for medical services. The credentialing process ensures that a highly educated and well-qualified provider is providing healthcare services and is being paid accordingly. However, the question is how to credential a provider with insurance companies. Well, there are some steps which need to be followed.

Providers should decide which insurance company they want to be credentialed to. They need to gather all documentation, make a CAQH ID, submit credentialing applications and wait for approval. On approval, a contract is signed to decide rules, and the provider is open to practicing medicine and bill insurance companies. Providers should also be prepared for audits and other irregularities, and they need to find solutions for such problems. We have also covered a blog related to getting credentialing with insurance companies as a mental health providers, so don’t forget to read it.

## FAQs

### 1. What are Insurance Credentials?

Insurance credentials are necessary documents including qualifications, licenses, certifications and work history. These credentials are checked and evaluated by the insurance companies to ensure that providers meet all the protocols defined by insurers.

### 2. What does it mean to be a Credentialed Provider?

A credentialed provider refers to a practitioner who has undergone the credentialing process by insurance companies to offer medical services to patients under the insurer’s health plan.

### 3. Who needs to be Credentialed?

Healthcare providers who wish to get reimbursement from the insurance companies for the medical services they provide should be credentialed. They can be physicians, dentists, NPs, PAs, Physical Therapists, Chiropractors and group practices.

### 4. What is Credentialing in Medical Terms?

In medical terms, credentialing is the process to verify the qualifications of a healthcare provider to ensure that he can meet the criteria for rendering medical services within a specific medical field. Training, certifications and work history are evaluated to make a final decision.

### 5. What is the Basic Process of Credentialing?

Credentialing process starts with application submission along with all necessary documents. All credentials are verified from the issuing bodies to check legitimacy and a decision is made about the approval or denial by the credentialing committee. After approval, the provider is allowed to practice and re-credentialing is also done after 3-5 years.

### 6. What is Insurance Panelling for Therapists?

Insurance panelling is the process in which therapists become the in-network provider for the insurance company and accept insurance payment from the patients. Therapists get on the insurance panel and it helps to reduce out-of-pocket expenses for patients. Patient base and revenue stream is also enhanced.

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