Credentialing Corner

# A Complete Guide for Credentialing with Insurance Companies

- May 28, 2024
- Posted by Kristen Edwards

04 Jan

If you have just started your medical practice, then it is no doubt that you must be looking for ways to apply for credentialing with insurance companies and get reimbursed timely for the services provided. These services can fall into a range of departments from clinical therapies to surgical procedures. The term for medical credentialing reimbursement is referred to as revenue cycle.

The first and foremost way to get started with the credentialing process is to get credentialed and get the provider participating contract from the insurance providers in your field of services provided in your area. Building a credible revenue cycle at the beginning of your medical practice can be daunting, however, with the right planning and accurate strategies, you can make the credentialing process far less intimidating.

To get away with the process, smoothly, we have compiled a guide to know how you can easily get credentialed with insurance companies when you start your medical practice.

## Prepare to apply for Credentialing with Insurance Companies

Credentialing is the process by which insurance companies authenticate the qualification, professional experience, and certification, and verify if you fall perfect on the internal requirement of the providers’ contract and the providers’ panel. For healthcare providers, insurance companies provide a web-based listing where healthcare providers are sorted according to their specialties, area, and experience. These listings are usually made for consumers to locate healthcare physicians according to their insurance providers.

To begin with your credentialing, you need to find the insurance plans that work around the location of your practice. Once you get credentialed and contracted with these insurance providers, consumers would be able to locate you in their providers’ panel and the specific specialty.

Insurance providers accept a physician in an insurance network after a two-phased process;

- Credentialing
- Contracting

The credentialing phase, as mentioned, is the process of verifying the professional certification and credentials to confirm that you meet the requirements needed to add a member to their network. The contracting phase represents the phase where the insurance company’s contracts with you to participate in the practitioners’ agreement where the practitioners are able to claim the reimbursement amount against their services.

### Which Insurance Companies Should you consider Credentialing with?

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As a provider, it’s important to choose which insurance companies you will credential with carefully. Each company has different requirements, and you’ll need to make sure you meet all the criteria before you apply. Credentialing with too many companies can be time-consuming and expensive, so it’s important to pick the right ones.

There are a few things you should consider when choosing which companies to credential with. First, look at the reimbursement rates offered by each company. Make sure you’re comfortable with the rate and that it will cover your costs. Second, look at the company’s network of providers. Make sure you’ll be able to work with the other providers in the network and that you’re comfortable with the company’s referral process. Finally, look at the company’s reputation. Make sure it’s a company you’re proud to be associated with and that you will be fully reimbursed without delay.

As a healthcare provider, you understand the importance of credentialing with insurance companies. Credentialing process can take time and can vary depending on geological, practice, specialty, and the field of services in a particular area.

### Credentialing and Contracting Requirements

- Once you affirm that you want to get credentialed, consider having a Tax ID that will be authorized once you establish a business registration for yourself like S-Corp, LLC, etc.
- If you’re up to working as a sole proprietor, then instead of operating under SSN, getting an SSN ID would work better.
- Get a liability insurance policy
- Establish an NPI for type 1 (individual) and type 2 (business entity)
- Make sure to work under a working license regardless of the location and state of your practice
- Establish and keep updating your CAQH profile
- Get to know the number of insurance networks you can work with and process credentialing for them.

### Proceeding with the Credentialing Process with Insurance Networks

Credentialing with insurance networks can be a time-consuming and complicated process. But it’s a necessary step if you want to participate in those networks and be able to accept insurance from patients.

There are a few things you’ll need to do in order to get credentialed. First, you’ll need to gather all the required documentation. This can include your medical license, educational certificates, and more. Once you have everything gathered, you’ll need to submit it to the insurance network. They will then review your application and make a decision.

The credentialing process can be lengthy, but it’s important to make sure you do it right. This will ensure that you can participate in insurance networks and provide the best possible care for your patients.

### Checklist for the Credentialing Process

The credentialing process can be complex, but this checklist will help you get started:

- Every insurance provider has a network provider service department where you can have information about their credentialing process. Get an application and be sure to get every possible information necessary for your credentialing.
- Be vigilant and take enough time to fill out your application properly mentioning your service areas and available locations. Date and Sign your application and attach the required documentation.
- Gather your requirements. You will need to provide documentation of your education, training, and experience.
- Start the application process. This will likely involve completing an online application and submitting supporting documents.
- Be sure that your CAQH profile is up to date and has the current information about your practice, insurance, licensing, etc. and you are not missing out on anything that may hinder the process of credentialing.
- Before submitting your application keep a copy of your application.
- Once the application is submitted, get it confirmed with the insurance provider that they have received your application, and make sure to keep taking follow-ups until your application gets approved and you get an effective date to participate in the agreement.
- Meanwhile when your application is in process, respond to information that insurance companies may require.
- Keep copies of all the applications you have submitted to the list of network providers.
- Pay the application fee.
- Wait for the decision. Once your application is reviewed, you will be informed of the conclusion.

### The Credentialing Process is complete! Now What?

There are a few things you should do now that you have gone through the credentialing process and been approved for your new credentialing network provider.

After your credentials have been processed, you will need to complete the following:

- Submit the completed forms to the Credentialing Office.
- If you have not already done so, you will need to have your fingerprints taken by a law enforcement agency. You will need to submit these to the Credentialing Office along with the completed forms.
- You will also need to conduct a criminal background check. The Credentialing Office will provide you with the necessary forms.
- Once the Credentialing Office has received all of the required documentation, they will issue you a credential.

### Billing to In-network Insurance Providers

If you’re a healthcare provider, you may be wondering how to bill in-network. In-network billing is a process where you work with your health insurance company to get reimbursement for the services you provide.

When billing in-network, providers must follow the protocols set by the insurance companies, which can vary depending on the type of service rendered, the type of insurance company, and other factors.

However, in-network billing can be a complex and time-consuming process, but there are some steps that providers can take to make it easier. First, providers should make sure that they understand the billing requirements of the insurance companies they contract with. Second, providers should develop a system for tracking claims and collections. Finally, providers should work with a billing service or consultant to ensure that claims are being filed correctly and in a timely manner. Other requirements would include;

- Prior to providing services, confirm that the patient is covered for the services
- Gather coinsurance and copayment at the treatment time to avoid surprises later
- Ensure submitting claims as soon as possible
- Know the timeline of your in-network provider to submit claims so you get your claims reimbursed timely.
- Know when your network provider pays for your services and promptly take follow-up where claims have not been paid in the provided timeframe.
- Pay insurance payments and invoice the secondary payers.
- Retain copies and documents of payments for EOBs.
- Keep yourself informed about the updated rules and regulations of the billing services and the insurance payers.

### Conclusion

Credentialing with insurance companies can be a daunting task but knowing the right plan of action can through you in the right direction that would put you at ease. Review the discussion and make sure that you follow every step to get reimbursed at the right time for the services rendered.

Related Articles:

- How to Become a Provider for Insurance Companies?
- How to Credential a Doctor with Insurance Companies?
- Contrasting Provider Enrollment and Credentialing Services

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