What is credentialing? Why is it so scary and takes such a long time? You’d think that if you went to med school, completed residency, and passed your boards, you’d be ready to start seeing patients right away…WRONG! Before you are able to start seeing your first patient, you need to complete the credentialing process with all insurance plans you’d like to participate with.
They don’t automatically start enrolling you with their plans, once you’ve passed your boards. In fact, even if you are credentialed with your current practice and decide to join a new practice or start one yourself, you will have to complete a new credentialing process. Not taking credentialing very seriously, can lead to major cash-flow delays and financial disasters.
Credentialing is a process that insurance companies do to verify all of physician’s licenses, education, background, and other information. Based on their clients’ (patients’) needs in specific territories, insurance companies decide how many physicians of different specialties they want to join their network.
They also develop specific contracts for physicians that set rates of reimbursements and rules of billing. The entire process can be very lengthy and it is important to leave ample time to complete it thoroughly and properly.
Here are a few tips for new practices starting out (this is only a guide; consult a professional for specific details):
- Get a legal name, tax ID, and group NPI for your new practice (you’ll probably want to consult an accountant and/or an attorney)
- Get a practice location, phone and fax number, and email address
- Get a bank account set up for the new practice
- Obtain a Malpractice Insurance
- Create a W-9
- Gather all of your licenses, DEA , CDC, and board certification (if applicable)
- Complete your hospital(s) affiliation/participation agreements/credentialing
- Complete a CAQH application—most commercial insurances will use it to verify credentialing
- Complete a PECOS application or reassignment of benefits (if practiced previously with another practice in the same locality)
- Contact every single payer and notify them that you are starting a new practice and want to join their network
- Follow-up with every payer weekly, and write down the date, reference number, and name of every representative for every call
- Read over your contracts or consult an attorney, if necessary
- Make sure you have an effective date and provider number for each payer (if available), once credentialing is complete
The process can take anywhere from 3-6 months to complete. Always allow sufficient amount of time before you start seeing patients. It is best to be aware of the steps involved and all necessary materials to gather and complete, before you set-out on your new venture. Hiring professionals with experience in credentialing is a good idea to ensure the process is done correctly and quickly.
Simply Remember: “Credentialing is a lengthy process; so be aware, prepared, and follow-up.”
If you have any questions, please contact us at firstname.lastname@example.org.