5 Minute Read: Contracting and Credentialing – A Getting Started Guide for New Clinic Owners

We get a lot of calls from new clinic owners who are overwhelmed at the thought of credentialing and have a tough time navigating the waters.  Of course we can help new clinic owners by selling services, after all we are a business, but we feel that most clinic owners (especially new clinic owners) should do the credentialing themselves and would normally do it themselves if they knew only where to begin and how to follow through.  And that is how we got here now: telling you how to do credentialing, pointing you the right direction, guiding you to success in a single blog post.

Breaking Ground

Decide your revenue strategy: private pay, medicaid/medicare, and/or commercial insurance. If you only offer private pay, the biggest question will be answered for you (Who will be paying you for your services?). This blog post does a great job summarizing how important the average revenue per session key metric can be.

If you are going to offer any type of insurance (commercial, state, government or other)  then you will want to  know what region you are in. Florida readers will want to use this link to find their region. Where are you located on the map? Make note of the region in your credentialing plan and keep it updated as you expand.

Clinic owners have a choice, choose a revenue model as either accepting only private pay, accepting Medicaid, Medicare or other state or federally funded insurance program, or accepting commercial insurances.

If you operate a multi discipline pediatric therapy outpatient clinic (physical location) in Florida we could easily probably guess your credentialing make-up as:

1. Medicaid
2. Optum
3. Sunshine
4. if Speech Therapy you probably are in network with Cigna (contact us now if you aren’t)

If you only offer home health American Specialty Health (ASH) is where you should look.

Next Steps

Your next steps now, is to contact each one of these insurance companies and learn about the process to join their network.

1. Initiate the process to Join their network.
   1. Each insurance company is different but they all have similar requirements:
      1. Compose a Letter of  Intent (LOI) that contains this basic information group name, tax id, address, phone and fax, services rendered, contact name, contact email, contact phone and fax.
      2. Compose a roster of providers using  a popular spreadsheet software like Google Sheets, or Microsoft Excel. Insurance companies sometimes have data requirements like first name, last name, SSN, NPI, CAQH#, provider type, credentials, and others.
      3. Get a copy of your W9 ready in PDF format (double check it! outdated W9’s that get caught later stymie the process.)
      4.  Get your billing information ready (some insurances want a billing form like the CMS1500 blocks 31, 32, and 33 to be completed)
   2. Submit your credentialing request
      1. Make sure all of your attached documents have been double checked for accuracy and completeness.   If you submit wrong information or incomplete information it will cause problems delaying the process.
      2. Some insurance companies have a portal to submit credentialing request, others want you to send an email to a specific address.  Some have both.
      3. Always get confirmation the company received your submission.
   3. Follow up through completion
      1. Each insurance company is different some have 30 day turnaround times, other 60-90 days. If you don’t know, ask them what you should expect.
      2. Major milestones you should achieve in this step is to
         1. Call and confirm they received your request to join the network (most people skip this step and regret it later)
         2. Follow up as needed until credentialing is done.
2. Perform maintenance tasks
   1. 1. ongoing credentialing
         1. as you hire new therapists or therapists go through life events (marriage/divorce (ie. name change) you will need to engage the insurance company.
3. Stay abreast of updates from the insurance company- and always have rate renegotiation top of mind.   Insurance companies won’t admit it, but they rank and grade providers in their networks.  How does your strategy match up to other clinics?

Now that you have a solid path forward, lets review other important things:

1. Credentialing will go smoother if the provider has a clean history. Any issues with background screenings, claims on eligibility or others will result in delays and an absent reimbursement rate. When filling out forms its best to provide all available information no matter your hesitation. Stated frankly- don’t duck questions. Do what you can to try and detect possible challenges in the beginning during the hiring process.
2. Implement an effective communication plan with your therapy staff and make sure you tell them your expectations of them.  The best place to start is before your hire a therapist.
3. Don’t forget the big picture. Your credentialing program should start with hiring and end with termination and everything in between (name changes, renewals, recred, etc.). If a credentialed therapist leaves your clinic, there is clean-up work required at the end.
4. When you call an insurance company its important to go prepared. We recommend reading  our tips for communicating with insurance companies.
5. Review 6 common credentialing mistakes and learn more on how to avoid them.