The Process of Provider Credentialing: Helping Practices Succeed

Provider Credentialing For Mental Health Providers and Health Care Practices

Opening a private practice takes a lot of time, money, patience, and some perseverance mixed with luck. Like starting a new business, there are a thousand things that must be done to open your doors. Healthcare businesses have their own set of unique hoops that they must complete before they can open their doors.

In your practice – whether that is mental health, medical, or whatever the case, you have to make sure that your clients or patients can pay for the services that they receive. In most small businesses, customers hand over plastic and payment is received, but in mental health, when clients hand you plastic, most often – it is their insurance card.

The burden falls on you to:

1. Accept that insurance

2. Bill that insurance

3. Receive the funds from that insurance card.

How do you make sure that you can do the above 3 things—it is a simple answer but a difficult process, “provider credentialing”. (Or you can just call us: 1-855-664-5154).

It is called many different things: credentialing, provider enrollment, insurance credentialing, medical credentialing, getting on insurance panels; it all is the same thing. It means that you have become “in network” with the insurance companies. Once you receive provider credentialing, you can now bill insurance and receive your payments as an “in-network” provider. Which usually means you can accept a lot of clients and your claims are paid on time.

So, who should you network with? Who should you get credentialed with?

This is not a general answer. Sure, there are some big names that you want to get in with: BCBS, Aetna, UHC, Cigna, Humana, and the list goes on. And there are important government companies that you may want to get networked with: Medicare, Medicaid, TRICARE (TRICARE changes names based on the location that you are in).

But, there are also some smaller companies that are unique to your area that you will want to credential with. Some people do not think about provider credentialing with the small companies, but in the end – they could pay out the most dividends.

Being a small fish in a big pond (BCBS – or name the larger companies) is a good idea, but being a whale in a small pond can be a great idea. Being in network with some of the smaller companies gives you access to clients and potential customers that will see you because no one else can. Being provider credentialed with BCBS is great, but there are thousands in your area completing provider credentialing with BCBS. So the next best thing, seeking provider credentialing with the smaller companies where there is no competition.

So, when do I start the provider credentialing process?

Start the provider credentialing process early on. First, it is best to get an office space, a business bank account, and a business organization together, but go ahead and plan the credentialing process. When getting credentialing, it is best to have a location mapped out, but the location can be changed (as long as it is in the same state) without a huge ordeal.

Next, get all of your information ready. You will need…

  • license information
  • background documents
  • insurance
  • copies of relevant information
  • and a CV that shows what you have been doing every day of your life since Kindergarten

Okay that last one might be a wee bit of an exaggeration, but it is important to show your activities since college. The CV/Resume must have a month and a year for every entry.

A realistic time frame, for provider credentialing is around 90-120 days. This is the average time for becoming credentialed with 8-12 carriers. 8-12 is a good number to start with if you are seeking to be full time. If you want to start part-time, consider starting with 5-7 panels, and then you can increase the panels later.

Each insurance carrier will have their own process, but first you must go through the process of “credentialing”. Credentialing means they verify everything about you. Remember the CV that records everything – this is why that is necessary. When that is complete – your file with all of your credentialing materials, goes to a committee and you either pass or fail. This is a 90-120 day process.

If you get approved, then you move to contracting. Contracting is the point where you receive the ability to be in network. You can review the contract from the insurance company and negotiate a favorable rate before signing. When you submit it, it will then take 30-60 days before you get a welcome letter. Considering the amount of time, you begin to see why provider credentialing is a necessary start to running your private practice. You don’t want to open your doors, and in month two of not seeing any clients, start provider credentialing. It could be months before the benefits of being in network kick-in, and they you are up the creek without a paddle.

Also, it is important to note – don’t expect the insurance to backdate your claims. Meaning, when you do get provider credentialing, do not expect the insurance company to accept the previous claims you can not submit. Until you are in network – you will be considered out of network.

So how do I start the credentialing process?

Hire us. We can provide you with a complete private practice provider credentialing solution to make the credentialing and contracting process go smoothly and efficiently as possible.

Provider credentialing process is necessary to getting your practice off the ground. It is the difference between barely making it and thriving. While it can be time consuming, we can help. Give us a call today at 1-855-664-5154 and someone will talk to you about getting on panels for a very reasonable price. Let us focus on what we do best, so you can focus on what you do best.