Credentialing FAQ

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For many healthcare organizations, credentialing can be confusing, overwhelming, and time-consuming.

At Credentialing Concepts, we provide clients with a full-service credentialing solution. Let us handle the complicated processes and the repeated follow-up calls with insurance companies, so you don’t have to!

Below there are some answers to some of the frequently asked questions about the credentialing process. Take some time to review the information below and call (314) 597-9747 or e-mail with your questions, and one of our specialists will be happy to help!

A panel is usually the equivalent of an insurance company; the term is used to refer to a panel of insurance plans. This is demonstrative that when a provider is on a panel, he or she can bill for all of the insurance plans under that specific panel.

At Credentialing Concepts, we use the term credentialing to encompass both credentialing and contracting phases of the credentialing process. Our credentialing specialists are trained to navigate both credentialing and contract proposals to ensure providers are correctly positioned on the panels. Any company, as an in-network provider, must undergo credentialing.

Once the provider is credentialed with a payor, they can bill that insurance company directly. Most panels will also provide “in-network” providers with referrals and preferential reimbursement rates. Insurance panels may split the credentialing process into two parts, the credentialing phase and a contracting phase. The credentialing phase is when an insurance panel will perform primary source verification on a provider to ensure that the provider meets the panel’s minimum requirements. Also, the panels may access the CAQH to assess the providers’ education and employment history.

Once the credentialing phase is complete, the insurance company will send the provider’s application to contracting. At this time, the panel may provide an offer to the practitioner or facility. When the contract is offered, it will usually include the fee schedule and CPT codes for which the provider is eligible to bill.

Any physician or other healthcare practitioner (i.e., a hospital, chiropractor, dentist, PT, OT, office, urgent care, etc.) who wishes to bill an insurance company as an in-network provider must undergo a process of credentialing. 

Council for Affordable Quality Healthcare, Inc. is a non-profit organization incorporated in California as a mutual benefit corporation. Formed by a number of the nation’s largest health insurance companies, CAQH aims to create a forum where healthcare industry stakeholders could work together to reduce administrative burdens for physicians, patients, and payers. Today, its mission is to accelerate the transformation of business processes in healthcare through collaboration, innovation, and a commitment to ensuring value across stakeholders, including healthcare providers, trade associations, and health plans. Most commercial insurance companies require that you have the CAQH profile completed before you begin the credentialing process. Panels use the CAQH to verify provider’s personal information as well as education and work history.

Almost all insurance panels will require providers to have or obtain a CAQH ID. If you don’t already have an ID, we can create one for you! Our specialists can complete an application for you. If you would rather, please visit CAQH ProView to start the process.

When an organization /provider becomes credentialed with insurance companies, the agency may bill the payor directly for services rendered. The credentialing process will increase revenue to your organization by increasing the number of patients that can access your facility and services.

If you are a fully licensed provider, even if you don’t have years of experience in the field, most insurance companies will accept you right away. Some panels have certain regulations and may require a specific amount of experience. Credentialing Concepts will be able to help you navigate these requirements when recommending panels.

Sometimes, but it is improbable. Our specialists have had success with medical credentialing such providers on a limited basis—generally in very underserved areas. Insurance companies typically look to network exclusively with fully licensed healthcare providers. Interns typically bill through a supervising provider.

APPs can be members of the medical staff and are subject to credentialing, privileging, and the peer-review process. The credentialing process is primarily the same for APPs as it is for physicians. For all APPs, primary source verification must be obtained directly from the school or designated verification source, such as the National Student Clearinghouse (NSC). Even if accreditation standards do not require it, an organization’s policies still apply even if the guidelines are more strict than the state law or accreditation requirements.

Proper credentialing with the insurance panels is instrumental for operating an insurance-based practice. Providers must be credentialed with each panel of payors if they wish to bill effectively and efficiently. If mistakes are made, the medical credentialing is not correct, your claims to the insurance panels can be delayed or even denied.

The credentialing process generally takes between 90-120 days, sometimes as long as 180 days. Typically, when a client requests our credentialing service getting your applications completed and submitted to insurance companies occurs within two business days. We then follow up proactively with insurance companies to ensure that your credentialing applications are processed and approved as soon as possible. One of the benefits of using Credentialing Concepts is we have direct contact with multiple insurance companies. In some cases, this can benefit you in receiving a quicker turnaround approval time.

A provider must be credentialed before being considered eligible to network with an insurance company. Recredentialing is done every 1-3 years after the provider’s original effective date. Re-credentialing is repeated fairly frequently to make sure that all of the information listed with the insurance panel is up to date and accurate.

The amount of time that it takes to complete the credentialing process varies by license type. The credentialing specialist will put in between 10 and 12 hours of work for each insurance panel for a standard outpatient practice. Sometimes, an appeal may have to be filed. If so, that process can add a minimum of 5 hours of work to that insurance panel. Facility-based services and DMEs will all take over 20 hours to complete the credentialing process.

Call our office at 314-597-9747 to get a quote

Some of the most popular and most prominent insurance companies are Aetna, Cigna, Magellan, Tricare, United Healthcare, Humana, Blue Cross Blue Shield, United Healthcare, Medicare, and many others. The popularity of individual insurance companies varies by location. The popularity of any given insurance company varies depending on geographical location.

You bet! We have credentialed thousands of providers across the United States literally! No matter where your practice/organization is, we have the experience needed to get you credentialed with insurance companies/ panels across the country.

Yes! Like insurance companies, EAPs are valuable third-party payers to be credentialed. The credentialing process for an EAP is very similar to being credentialed with insurance companies. Some of the major insurance companies already offer an EAP. Popular EAPs include ComPsych, Optum, and Cigna.

We can help! One of our credentialing specialists will speak with you and can help you to select the panels in your area that will be most beneficial for you and your organization or practice.

Fully licensed, we should have no problem identifying and selecting numerous insurance companies and third-party payers for you to be credentialed. Depending on the area, some panels are very selective or closed even. In these instances, we will discuss with you the likelihood of a successful medical credentialing process with those panels. We want our clients to get the most out of their medical credentialing investment, but we can never guarantee that insurance panels will accept you.

Yes! When contracting services with Credentialing Concepts, you will be able to choose which payers you want to be credentialed. Typically, outpatient physician providers credential with 7-8 payors. In-patient, hospital-based physicians typically credential with 10-15 payors. Physicians working near or in a tri-state area may want to consider credentialing with up to 25 payors. Behavioral health practitioners (PT, OT, ST, ABA, etc.) will typically want an affiliation with 6-7 payors.

Sometimes, when panels say they are closed, they will still accept providers, but only on a limited basis. In this case, we can and will submit an appeal when possible to the insurance company on your behalf. During a request, we will try to connect with the insurance company representative assigned to your area. We will then stress essential parts of your qualifications and clinical practice. For instance, your specialty that the insurance company may desire, or you are practicing in an underserved neighborhood. We do have some success with many of our appeals. However, if a company is saying that their panel is closed, it may be beneficial to get on the panel at a later time.

This situation is infrequent as most insurance panels consistently look for new providers to add to their network. More providers mean more patients; more patients means more revenue. If panels are closed, we will submit a formal appeal on your behalf. Whenever possible, we will advocate for you with the insurance companies. We can use your training and specialty to make a case as to why you are unique and why you should be allowed onto the panel during the appeal process. We have had a high success rate when it comes to the approval of appeals.

An NPI 1 identifies a physician as the rendering practitioner or the specific one providing the service. NPI 1 is like your social security number within the medical community. A physician will only have one NPI1 for the duration of their career; this identifier is unique to the practitioner.

An NPI 2 is an organization identifier. It identifies the place/organization the practicing physician is providing service. If the practitioner works for an agency/organization, this would be the employer’s company name. If it is a private practice, this would be the name of the business. 

It would be recommended that anyone whose business has a tax ID acquire an NPI 2. The number allows your contract with insurance panels to be at the organization level for applicable panels from a credentialing perspective. Then, the NPI 1 is linked to the NPI 2 for billing purposes, making sure the business is paid for the practitioner’s services. Incoming revenue is especially important as you grow your business and your medical team.

If your business has a tax ID number, Medicaid, Medicare, and BCBS require the NPI 2 to credential with them.

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