Start your insurance contracting/credentialing now!
Yes, the dominating trend over the last 20+ years has been hospital systems employing doctors and buying practices. However, many sources, including MGMA and Modern Healthcare, have reported that hospital systems lose approximately $150,000 to $200,000 yearly per physician. Recent changes to outpatient hospital payments, such as the elimination of facility reimbursement, have added to hospital’s problems. To stem these losses, productivity demands and salary reductions are placed on providers, increasing dissatisfaction, burnout and defections.
While new medical school graduates have little choice but employment, physicians further along in their careers are eyeing independent practice. But there’s precious little if any instruction given in school about the complexities of medical entrepreneurship. One of those seldom understood and potentially devastating pitfalls is insurance network contracting, commonly referred to as “credentialing”.
Establishment of new federal tax ID (TIN) and group national provider identifier (NPI) are first steps in starting a practice. Assuming the provider has been treating Medicare and Medicaid patients, adding the new TIN and NPI to the “straight” government programs is fairly simple. Basic information such as the address and phone number are required. However, other carriers require new contracts for the new practice.
Most patients choose a commercial Medicaid intermediary or a Medicare Advantage plan to increase accessibility and lower cost. Therein lies the rub. As an example; if you see a Medicaid eligible patient that’s designated United Healthcare as their carrier and you are not in the UHC network, even if you are an enrolled Medicaid provider, you will NOT be paid. You can’t bill the patient or Medicaid directly.
In commercial carrier situations, “out of network” payments to the provider are lower, patient deductibles are predominantly higher and some plans have no out of network benefits at all. Some providers opt to stay out of network and not treat those with government benefits, but that’s another topic.
Securing in-network status requires submission of ones curriculum vitae, references, employment history, attestation to any malpractice findings, and more – on specified forms, and following the protocols that each carrier demands. They are all different. Simplifying the process somewhat is the Counsel for Affordable Quality Healthcare (CAQH) database. Enter the required information once in CAQH and when you grant permission many carriers will use it for much, but not all, information they require.
But applying for credentialing is not enough.
Follow up on the applications is required and each carrier has their own timeframe to accept or deny. Allow 120 to 180 days prior to treating patients for commercial carriers and the government coverage plans they offer to grant you network status. Do NOT see Medicaid patients that have designated a network before your in-network status is granted if you wish to be paid. They will NOT back date your network acceptance.
Different from commercial, “straight” Medicare and Medicaid will pay for dates of service commencing with the date they received an application. They do however enforce a limited time frame for responding to errors in the application, at which point the application date and effective date may be pushed back.