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Medical Credentialing, Insurance Credentialing and Primary source verification.
In the past, healthcare professionals viewed getting enrolled in an insurance company’s preferred provider network, also known as medical credentialing, as a non-essential step in developing their medical practices or increasing their patient base. This was only a couple decades ago.
In the past, patients did not expect every healthcare provider to accept their insurance, and some areas of healthcare, such as mental health services, were not even covered by most insurance plans. Additionally, many patients had “out of network benefits,” which meant that they could see any doctor they chose and then file for reimbursement from their insurance company afterwards. But the healthcare industry has undergone a significant change and now the expectation is that providers participate in insurance networks.
Nowadays, it has become imperative for physicians and healthcare providers of various types, such as chiropractors, nurses, psychologists, professional counselors, and many others, to participate in insurance networks, or what is commonly referred to as “medical credentialing.” This is a requirement in part because more individuals in the United States have health insurance coverage than ever before. Additionally, people today expect their healthcare providers to accept their insurance, which means if healthcare providers are not participating in a potential patient’s insurance plan, they are likely to lose that patient to a rival practice.
Medical Credentialing / Provider Enrollment Key Points
Medical Credentialing (sometimes referred to as “insurance credentialing” or “provider enrollment”) is the process of becoming affiliated with an insurance company so that you (the medical provider) can accept third party reimbursement.
While important for the success of a clinical practice, “getting credentialed” on insurance panels is often an unwelcome distraction from providing quality care to patients. Enrollment applications can be 30+ pages long, and to ensure smooth processing there’s a lot of necessary, time consuming, follow-up.
Our medical credentialing service exists to take the hassle out of getting “in network” with insurance panels. We also offer Expert Medical Credentialing for Nurses, Doctors and Physicians. Find out more about Nurse Credentialing and Doctor/Physician Credentialing.
There are a few ways to calculate which are the the biggest insurance companies in the United States. Value of the company, lives covered, company revenue… regardless of how you calculate who’s the biggest, some of the names appear again and again. These are the 800 pound gorillas. These are the insurance companies you very likely will want to work with.
According to 2018 data from the NAIC, Insurance Business America listed the 10 biggest health insurance groups in the U.S. They are:
1. UnitedHealth Group: $156.9 billion, Market share: 14.2 percent
2. Kaiser Foundation: $93.2 billion, Market share: 8.5 percent
3. Anthem: $67.2 billion, Market share: 6.1 percent
4. Humana: $56 billion, Market share: 5.1 percent
5. CVS Health (Aetna, Coventry): $55.4 billion, Market share: 5.0 percent
6. Health Care Service Corp: $36.9 billion, Market share: 3.4 percent
7. Centene Corp: $36.3 billion, Market share: 3.3 percent
8. Cigna: $29.3 billion, Market share: 2.7 percent
9. WellCare Health Plans (Centene): $20.5 billion, Market Share: 1.9 percent
10. Molina Healthcare: $18.5 billion, Market share: 1.7 percent
While in some ways insurance plans are more limited than in the past years (with HMOs and the lack of out-of-network benefits), in other ways patient’s insurance plans are much more robust.
Medical credentialing has become more important as health insurance plans have become broader in regards to the scope of services they cover. These changes include Mental Health and Behavioral Health parity (see the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA)), less restrictions on pre-existing conditions (according to healthcare.gov “All Marketplace plans must cover treatment for pre-existing medical conditions. No insurance plan can reject you, charge you more, or refuse to pay for essential health benefits for any condition you had before your coverage started. Once you’re enrolled, the plan can’t deny you coverage or raise your rates based only on your health.”), and even the coverage of supplemental services such as physical therapy, massage therapy, acupuncture and some holistic medical services.
Unfortunately for some, insurance panels (that is, preferred provider networks) are becoming increasingly full, meaning the process of getting on insurance panels is becoming more difficult everyday as insurance companies close provider networks and make the barrier for physicians, counselors or any health professionals higher and more difficult to climb.
**That being said, some panels that claim to be “closed” are really just being highly selective about which providers they are adding. Knowing how to position one’s experience and practice can go a long way when it comes to getting into “closed” panels.**
The process of getting on insurance panels (if you’re taking a DIY approach) can be both challenging and lengthy. It generally takes between 3-4 months to submit the necessary paperwork, tender supplementary documentation, and correspond with insurance companies’ credentialing departments, before getting approved to join an insurance panel. However, at times the process can move along much faster. For example, Employee Assistant Programs (EAPs) tend to process in as little as 4 weeks. However, on the other hand, if an insurance company is running behind, or if there’s a problem with a physician’s/healthcare provider’s application, the medical credentialing process could take even longer than 4 months.
Because of the large amount of paperwork and correspondence required, medical providers generally find the process to be very time consuming.
Let us help you with your practice’s medical credentialing, give us a call today: 209 232 6222 , 209 208 5666
Are you ready to expand your patient base and take your practice to the next level? Call Us now!
We’ll work with you to get your practice enrolled and accepted by insurance providers. Don’t miss out on potential patients,
Physician Credentialing Process Flow
Credentialing & recredentialing is an on-going process and must be redone every 3-5 years. medicalcredentialing as a company offers complete credentialing and
re-credentialing. We notify you of expiring documents and ensure timely re-credentialing/ revalidation.
Step 1
Collect all the required documents from physicians for filling the credentialing applications.
Step 2
Develop an appropriate credentialing strategy by selecting the top payers to which the physician practice send claim
Step 3
Audit the application for accuracy & completeness – then file the application
Step 4
Submit the filled-up credentialing forms to the insurance carriers either chosen by the physicians or recommended by our expert credentialing specialist.
Step 5
Follow up with the insurance carriers on a regular basis to track the status of the application.
Step 6
obtain executed copy of contract along with provider enrollment number from insurance carriers and communicate to the physicians
An Insurance and Medical Credentialing Service Can Help
if you’re looking for a medical credentialing service that can take the burden of credentialing off of your plate, we can do that too.
There are few things in life and business that truly pay for themselves. We’ve set our prices to be affordable, so much so that if you turn just one potential patient away—just one—you would have been better financially having us help you with your medical credentialing. The value of just one client or patient greatly outweighs the cost of medical credentialing.
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