Contracting and credentialing feels great.
When I first started applying to insurance companies, I did not realize that the contracting and credentialing processes were different. In residency, fellowship, and my first attending job, the only thing I had to deal with was the credentialing process. My ignorance led to delays that you should be able to avoid. There are companies you can hire for contracting and credentialing if you don’t want to do it yourself. I had the time and inclination, so I went through contracting and credentialing by myself. It can be a slow, frustrating process so be sure to give yourself plenty of time and remember that the people you are dealing with are nice people just doing their jobs.
As with all contracts, everything is negotiable. This is particularly true if you are not part of an independent physician association (IPA). If you are an IPA member, the IPA negotiates terms on your behalf which you then have to accept. Conventional wisdom states that being part of an IPA provides additional negotiating power and will result in more favorable terms for the members. However even if you negotiate for your own practice, you will likely be able to increase your reimbursement rates substantially.
Contracting
As the name implies, contracting with an insurance company is like contracting with any other sort of company. You make a formal agreement to see their patients for X reimbursement with Y & Z stipulations. These contracts tend to be very long and can be complex. However, you must read the whole thing.
I recommend making a spreadsheet for your future reference with all the different payers that outlines the following:
Contracted plans
Reimbursement
Time to file claims
Initial contract term
How to renew contract
How to terminate contract
The contracted plans part can be a little tricky. A given insurance company may have many different health plans available to patients in your area, and you may not be contracted with every single plan. Your front desk staff should get a list of all the individual plans with which you are contracted by the time you’re finished with the contracting process.
Applications to contract with an insurance company are handled by the contracting team, NOT the credentialing team. I recommend scouring each company’s website to find their contracting contact information. Typically this is in the form of an “initial application form” or “letter of intent” on their site. You must then wait 45-60 days for a response. I started calling the number provided after about 30-45 days once per week to ensure that I heard back.
Most contracts include a provision for notifying the contracted company about major changes via mail/email and not about minor changes. You would do well to go to each payer’s website quarterly to look for any changes that affect your practice.
Whenever you get a contract for review, make sure you ask for higher reimbursement. I cannot stress this enough. All commercial payers but one increased my reimbursement rate to a level I deemed sufficient when I asked for it. You can break down the negotiated rate by CPT code grouping to make the most advantageous reimbursement environment for your practice as possible.
Credentialing
Credentialing can only occur AFTER contracting is complete. You cannot become credentialed with a payer until your practice is contracted with them. This process is much like credentialing at a hospital or surgery center. It revolves around proving to the insurance company that your professional credentials are valid. You will have to provide your medical license number, practice address, NPI, employer identification number, training history, etc.
Fortunately there is a common application available at CAQH for most commercial payers. Medicare does not accept the CAQH (you must go through PECOS). You should start this about 6 months before you are set to open doors on your practice. It is a lengthy form and will likely take a few hours to complete. However you will be unable to fully complete it without your practice address, EIN, etc. So although you should start filling this out early, you will not truly finish it until after you’re nearly ready to go. Much like credentialing at a hospital or ASC, you should expect this process to take about 3 months from the time you submit your credentialing application.
For both contracting and credentialing, Aetna dragged their feet the most. It took a lot of proactive contact on my part to bring a contract to the table at all. Then it was several months after negotiating and signing the contract that I was able to be credentialed. The entire process was far less onerous with the other payers.
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