Credentialing tips

Should I hire someone to do my credentialing?

Are you capable of writing down your name, phone number, address and medical license, DEA and other numbers? Do you have a finger and a phone? If you said yes to the above, you can do your own credentialing.

Did you hire a “expert” to fill out your residency applications? A lot of these companies will use fear mongering to try to get you to cough up a few grand of your money, telling you how “complex” credentialing is and how they are “experts” at doing it. Don’t bite. Just because they take your money doesn’t mean they will follow up, follow through, or do a good job.

I personally know someone who paid a lot for credentialing but they didn’t follow through so she had to make a bunch of phone calls herself. No one cares more about getting paid than you do. Your expert credentialers don’t care as much as you do.

Another friend hired a credentialing company. They forgot to reattest for his state’s Medicaid program. Fortunately once he reattests he can go back and bill retroactively, but this would be a disaster if he were seeing patients for free. (As an aside, you need to reattest for CAQH every 90 days. They send you email reminders but I also set a alarm in my iPhone).

Hiring a credentialer is a waste of money. Ho Sun lost faith in his consultant when they told him the wrong thing for his Medicare application. It isn’t rocket science. If you are truly busy with another job, get a relative or trusted friend to do it. Here’s a post about how long it typically takes for credentialing.

If I already practice in a area do I need to start from scratch with credentialing?

This is a common question that comes up in our soloeyedocs thread. It depends on the insurance.

For Medicare, you need to credential for every NPI2. So if you are going solo, even if you are active for Medicare in your locale, you will need to recredential. If you work one day a week at another office as an employee and they do the billing for you, you will need to recredential.

For commercial insurances it depends on if the credentialing is individual or delegated. If a plan is delegated it is credentialing a practice, and any doc in the practice is credentialed when the practice submits a form. This makes it harder to get in network as an individual.

If you have a individual contract with the insurance company, frequently you can just phone provider services and tell them you want to add a new address and TIN. In fact, one of my commercial plans told me their network was full when I made a inquiry in their website. When I contacted them to tell them I wanted to change my practice address and TIN, the contract was in my inbox two days later! Some plans made me credential from scratch even though I was already in network.

One managed Medicaid plan initially told me their panel was full, but I pointed out that I was credentialed in my previous job and the panel was the same size. So after going back and forth with the provider rep they let me in network. It’s not a huge plan where I see a ton of patients, but it was nice to get in network.

As mentioned earlier, you can use IPAs and ACOs to get in network. The good thing about being a independent doc is that you can join multiple IPAs and hospital networks, so you might actually be in more plans than if you were a employee of a single hospital network, when the other competing hospital network in town won’t let you in network!

Should I be concerned if a network is closed?

Keep on trying. Make inquiries every six months. Another idea particularly if you are a sub specialist is to contact the provider rep and explain the situation (there is only one other glaucoma doc in a 25 mile radius).

Many Medicare advantage plans are run by a third party under the name of a insurance company like AARP or BCBS. Unless you work for a big practice in town, which has likely signed a low reimbursement contract in exchange for volume, you can’t get into network.

For Humana, I didn’t get into network until my fourth year in practice. It’s not like my business failed because I was out of network for some Medicare advantage plans and Humana. Indeed, one of my friends in a different city couldn’t get in network for UHC and easily expects to make $400,000 this year.

Should I negotiate rates with my insurance company?

Before you sign your contract, find out what the reimbursements will be for your most common codes, such as 92004, 92014, 92134, 92083, 66984 etc. (note: no one ever told me to do this and I just blindly signed the contracts. While just like everyone else I’d rather get paid more than less, I did just fine).

You can try to negotiate but in urban areas this might be difficult. After a year or two you can request re evaluation of certain codes. If the insurance company doesn’t negotiate and their rate is too low you can always drop them. More importantly, if a company tries to nickel and dime you with denied claims and prior authorizations, drop them (thankfully this hasn’t happened to me yet).

You might think the rates look low, but one important thing to keep in mind is that for most ophthalmologists, Medicare is the highest payer for office visits (testing and surgery is usually at Medicare rates). This is very different from other specialties where Medicare is one of the lowest payers. Some Medicare advantage plans just pay a percent of the Medicare fee schedule, like 80, 85 or 90%.

The bottom line is that your practice will be successful even if you can’t get into network for every plan, and despite what they say about big groups holding sway with insurance company negotiations, solo docs do very well especially if they can control their expenses.

5 thoughts on “Credentialing tips

  1. An affordable option to consider is to search for IPAs (independent physician association) in your area. A local hospital where I am (pretty big midwestern city) has an IPA that will credential you on “most” commercial panels (I don’t think mine does Medicare/Medicaid for some reason) . The IPA charges 300 dollars, which is low compared to the thousands mentioned in the post above. The only requirement for the IPA I am working with is I must take call for one of the hospitals within their system, which I do anyway. Different IPAs May have different requirements. They also charge the 300 dollars because some people just get credentialed and then leave the IPA, so the 300 is basically covers their administrative costs.


  2. Great post. I need some advice. I am planning to go solo, no clinic, just inpatient consults, therefore I will not have general business liabilities, of course I will have malpractice insurance. Should I form an LLC or continue as a solo proprietorship before starting the credentialing process with private health insurance companies and Medicare? Is there any strong reason to form an LLC in my particular situation?


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