Credentialing

• • It varies by payor and can be based on their backlog of applications.  Typically, the process is between 60 and 120 days. It can sometimes take even longer.   Commercial payors always tend to take the longest amount of time.  
  • The credentialing process duration can vary significantly depending on several factors, including the payer (Medicare vs. commercial insurance), the completeness of the application, the complexity of the provider's credentials, and the efficiency of the credentialing organization involved. 

• • Initial Enrollment: The process for initial Medicare enrollment can take around 60-120 days or longer. This includes submitting the CMS-855 form and required documentation to the Medicare Administrative Contractor (MAC). Delays can occur if there are errors or missing information in the application.
  • Revalidation: Medicare providers are required to revalidate their enrollment every few years. The revalidation process typically takes 60-90 days, although it can vary.

• • Application Completeness: Ensuring all required documents and information are submitted accurately and promptly can significantly impact how quickly the process moves forward.
  • Verification Process: Verifying credentials, such as medical education, training, licensure, and work history, can take time, especially if there are discrepancies or delays in receiving verifications from third parties.
  • Payer Requirements: Different payers may have varying requirements and processing times, which can affect how long credentialing takes with each specific insurer.

• • The credentialing application process for payors (insurance companies) typically involves several steps to verify and evaluate a healthcare provider's qualifications and eligibility to join their network. The application process with payors varies from state to state and payor to payor.
  • Some payors support an online application process through Availity; some payors have an online portal for application submissions; and some payors still utilize a paper application to be completed as a PDF or by hand and submitted via mail or email. Medicare enrollment is standard across all states, completed via PECOS. 
  • With some payors utilizing CAQH data for credentialing purposes, providers must maintain and update their CAQH profiles as well.

• Credentialing is a critical task, and the costs can vary based on several factors – the current credentialing status, the number of offices within the practice, the number of providers, the number of payors, and the payor mix.   The costs will vary from company to company but the level of service and detail also varies.  
• Credentialing service providers typically charge for their services in various ways, depending on the complexity of the credentialing process and the specific needs of the healthcare provider or practice. Here are our methods of charging for credentialing services:
  • Flat Fee: Many credentialing companies charge a flat fee for their services. This fee is often based on the type of provider (e.g., physician, nurse practitioner), the number of payers the provider needs to be credentialed with, and the complexity of the credentialing process. Flat fees provide transparency and clarity regarding costs upfront.
  • Per Provider Fee: Some credentialing services charge on a per-provider basis. This means that each provider requiring credentialing is charged a specific fee. This method is straightforward for practices with a small number of providers or those adding providers sporadically.
  • Hourly Rate: In some cases, credentialing services may charge an hourly rate for the time spent on each provider's credentialing process. This can be more flexible for practices with varying credentialing needs or those that require extensive support for complex cases.
  • Additional Fees: There may be additional fees for services such as expedited credentialing, provider updates or changes, appeals for denied applications, or other specialized services. These fees are usually outlined in the service agreement or contract with the credentialing provider.   We also provide other services such as CAQH enrollment, which is the online provider data collection tool as well as PECOS enrollment, which is the online Medicare database.  
  • To reduce costs, we can complete the applications and allow someone from your office to perform the follow-ups.  
  • Contact us to discuss pricing.

• • Yes, it is possible for someone from your team to assist in the credentialing process to help reduce costs to the practice or provider. Here are some ways your team member can contribute effectively:
    • Data Collection and Organization: Your team member can gather and organize all necessary documents and information required for credentialing, such as medical licenses, certifications, malpractice insurance, DEA registration, education history, and work experience. This ensures that the credentialing service provider receives complete and accurate information promptly.
    • Application Completion: They can assist in filling out credentialing applications and forms based on the information provided by the provider. This includes ensuring all required fields are completed correctly and any supporting documentation is included as needed.
    • Follow-Up and Communication: Your team member can communicate with the credentialing service provider or directly with payers to follow up on the status of applications, provide additional information if requested, and address any questions or concerns promptly.
    • Verification Assistance: They can help facilitate the verification process by ensuring that requests for information from third parties (such as medical schools, previous employers, or licensing boards) are submitted in a timely manner and responding promptly to any inquiries.
    • Document Management: Maintaining a well-organized system for storing and accessing credentialing documents can streamline the process and reduce delays. Your team member can manage document storage and retrieval, ensuring that all documents are kept up to date.
    • Quality Control: They can review completed applications and documentation for accuracy and completeness before submission to the credentialing service provider, minimizing the risk of errors or omissions that could delay the process.

• • Your team will need to be involved in the credentialing process mostly on the front end – gathering/organizing the necessary practice information, details on the practice setup, financial information, current provider information, etc. Once the necessary documentation and provider details are supplied to the Legacy team, your team can then have as little (or as much) involvement as you would like.

Commercial contracts between healthcare providers (such as physicians, hospitals, clinics) and insurance companies (commercial payers) typically outline how providers will be reimbursed for services rendered to patients covered by the insurance plan. Here are some common methods of reimbursement used in commercial contracts nowadays:

1. Fee-for-Service (FFS):
   • Description: Providers are reimbursed based on the fee schedule negotiated between the provider and the insurance company. Each service or procedure performed by the provider has a predetermined reimbursement amount.
   • Variations: Fee-for-service arrangements can vary based on the complexity and type of service provided. Some fee schedules may be based on Medicare rates, while others may have proprietary fee schedules.
2. Capitation:
   • Description: Providers receive a fixed, per-member per-month (PMPM) payment from the insurance company for each patient assigned to them, regardless of the services provided.
   • Payment Model: Capitation shifts financial risk to the provider, as they must manage patient care within the fixed payment amount. It incentivizes preventive care and efficient management of resources.
3. Episode of Care/Bundled Payments:
   • Description: Providers receive a single payment for all services related to treating a specific condition or for a defined episode of care (e.g., joint replacement surgery).
   • Payment Structure: This model encourages coordination among providers and can lead to better care outcomes and cost containment.
4. Pay-for-Performance (P4P) or Value-Based Reimbursement:
   • Description: Reimbursement is tied to performance metrics related to quality of care, patient outcomes, and cost efficiency.
   • Incentives: Providers may receive bonuses or penalties based on their performance compared to predefined benchmarks or quality measures.
5. Shared Savings:
   • Description: Providers share in the savings achieved by delivering care more efficiently than expected, compared to a baseline or target cost.
   • Payment Mechanism: Savings are typically calculated as a percentage of the achieved cost savings relative to the baseline, with providers receiving a portion of those savings.
6. Risk-Sharing Models:
   • Description: Providers and payers share financial risk for the cost of healthcare services. This can include upside risk (shared savings) or downside risk (shared losses) depending on the performance against predefined targets.
7. Global Payments or Capitated Payments:
   • Description: Providers receive a lump sum payment to cover all healthcare services for a defined population over a specific period.
   • Scope: Payments are often adjusted based on the health status and demographics of the covered population.

When considering whether to outsource credentialing for your practice, it's essential to make an informed decision. Here's some advice to help you evaluate the potential benefits:

Pros of Outsourcing Credentialing:

• Expertise and Efficiency:
  • Credentialing companies specialize in navigating the complexities of credentialing processes, including various payer requirements and regulatory compliance. They can streamline the process, potentially reducing credentialing timeframes and minimizing errors.
• Time Savings:
  • Outsourcing credentialing allows your providers and staff to focus more on patient care and practice operations, rather than administrative tasks.
• Cost Efficiency:
  • While there is a cost associated with outsourcing, it can be cost-effective in the long run by reducing the administrative burden on your practice and potentially minimizing revenue losses due to delayed credentialing or errors.
• Compliance and Accuracy:
  • Credentialing companies stay updated on the latest regulatory requirements and ensure all provider credentials are up-to-date and compliant, reducing the risk of compliance issues or denials.
• Network Expansion:
  • Outsourcing credentialing can facilitate smoother participation in insurance networks and expedite provider enrollments with various payers, potentially enhancing your practice's ability to attract new patients.

If a new practice or a new location is told that a payor's network is "closed," it typically means that the insurance company is not currently accepting new providers into their network for that particular area or specialty. Here’s how to approach this situation:

1. Understand the Reason for Closure:
   • Reasons Vary: Network closures can happen for various reasons. It could be due to the insurance company reaching its desired provider capacity for that geographic area or specialty, or it might be related to specific network management strategies or financial considerations.
   • Temporary vs. Permanent: Determine if the closure is temporary or permanent. Insurance companies periodically reassess their network needs, so a closed network might open up in the future.
2. Explore Alternatives:
   • Other Insurance Companies: If one payor has a closed network, explore contracting opportunities with other insurance companies that operate in the same geographic area. Not all insurers will have closed networks, so expanding your search can increase your chances of contracting.
   • Different Plans or Products: Sometimes, a payor's network closure applies to specific plans or products only. Inquire if there are alternative plans or products within the same insurance company that might have open networks.
3. Networking and Relationships:
   • Network with Colleagues: Reach out to colleagues or peers who have contracts with the payor in question. They might have insights into network openings or strategies that could help navigate the contracting process effectively.
   • Utilize Professional Organizations: Industry associations or professional organizations often provide resources and networking opportunities that can help in understanding contracting processes and finding solutions.
4. Persistence and Communication:
   • Follow Up: Even if initially told the network is closed, periodically follow up with the insurance company. Networks can change, and new opportunities might arise in the future.
   • Build Relationships: Establishing a positive and professional relationship with the insurance company's provider relations or contracting team can sometimes open doors or provide insights into future opportunities.
5. Evaluate Business Strategy:
   • Patient Population: Consider the patient demographics in your area and their insurance coverage preferences. This can help prioritize which payors to target for contracting efforts.
   • Long-Term Planning: If network closure persists, evaluate long-term business strategies that might involve diversifying services, expanding into different geographic areas, or adapting to changing payer landscapes.