If you’re running a healthcare agency or planning to start one, getting credentialed with private insurance companies is key to expanding your client base and ensuring a steady stream of reimbursements. Credentialing with private insurers allows you to bill insurance companies directly for services rendered, making your agency more accessible to a wider range of patients. But the process of getting credentialed can feel complex, especially if you’re unfamiliar with the steps.
Why Credentialing with Private Insurers is Important
Credentialing with private insurers opens up a large pool of potential clients who rely on their health insurance to cover medical services. Here’s why it’s crucial:
Access to More Patients: Many patients will only seek care from providers who are “in-network” with their insurance. Credentialing with major insurers allows you to be listed as an approved provider.
Steady Revenue Stream: Being credentialed means you can bill insurance companies directly, ensuring that your agency gets reimbursed for services.
Increased Credibility: Credentialing with major insurance companies signals to patients and other healthcare providers that your agency meets industry standards for quality care.
Step 1: Identify the Insurance Companies You Want to Work With
Before starting the credentialing process, you need to decide which private insurance companies you want to enroll with. Focus on the major payers in your area and any insurers that are popular among your target patient population.
Some of the major private insurance companies to consider include:
- Blue Cross Blue Shield
- UnitedHealthcare
- Aetna
- Cigna
- Humana
It’s also important to consider regional or local insurers that might be prominent in your area. Researching which insurance plans are most commonly used by your potential clients will help you decide which insurers to target.
Tip: Check with colleagues or other healthcare providers in your area to find out which insurers they work with and which payers offer the most consistent reimbursements.
Step 2: Gather the Necessary Documentation
Private insurers will require a range of documents to verify that your agency and staff meet their standards for care. Before applying, make sure you have all the necessary paperwork ready to streamline the process.
Here’s a list of common documents you’ll need for credentialing:
Business License: Proof that your agency is legally registered and licensed to operate in your state.
Tax Identification Number (TIN): Also known as your Employer Identification Number (EIN), this is required for tax purposes and billing.
Professional Liability Insurance: You’ll need to show that your agency has sufficient malpractice and general liability insurance coverage.
Proof of Accreditation (if applicable): Some insurers may require your agency to be accredited by a recognized body, such as The Joint Commission or the Accreditation Commission for Health Care (ACHC).
Staff Licenses and Certifications: For agencies that employ healthcare providers, you’ll need to provide proof that your staff members (nurses, therapists, etc.) are properly licensed and credentialed.
National Provider Identifier (NPI): Ensure that your agency and all healthcare professionals within it have an active NPI, as this is required for billing insurance companies.
Step 3: Submit Your Application
Each insurance company has its own credentialing process, but the basic steps are similar. You can typically begin the application process through the insurer’s website or by contacting their provider relations department.
How to Apply:
Contact the Insurer: Reach out to the insurer to request a credentialing packet or application. Some insurance companies have online portals for submitting applications, while others may require paper applications.
Complete the Application: Fill out the application forms carefully, providing detailed information about your agency, services, and staff. Be sure to include all required documentation, as missing paperwork can delay the process.
Provider Enrollment Systems: Many insurers use CAQH ProView, a central system for provider credentialing, to streamline the process. If you haven’t already, create a profile on CAQH ProView and submit your information. Once your profile is complete, insurers can access it for credentialing.
Submit Your Documentation: Along with the application, you’ll need to upload or mail all necessary documents. Make sure everything is accurate and up to date to avoid delays.
Tip: Double-check each insurer’s specific requirements, as some may require additional documentation or specific forms beyond the basics.
Step 4: Undergo a Review Process
After submitting your application and documentation, the insurance company will begin the review process. This typically includes verifying your agency’s credentials, reviewing staff qualifications, and ensuring that your agency meets their standards for care.
What Happens During the Review:
Verification: The insurance company will verify your licenses, certifications, insurance coverage, and other key credentials.
On-Site Evaluation (if applicable): Some insurers may require an on-site inspection of your facility, particularly if you operate a clinic or healthcare facility.
Peer Review: In some cases, insurers may conduct a peer review process, where other healthcare providers evaluate your qualifications and standards of care.
This review process can take anywhere from 30 days to 6 months depending on the insurer and the complexity of your application.
Tip: Follow up with the insurance company if you haven’t received any updates after a few weeks. Keeping in contact can help ensure that your application stays on track.
Step 5: Contract Negotiation
Once your application is approved, the insurance company will send you a provider agreement or contract outlining the terms of your relationship, including reimbursement rates, payment timelines, and your obligations as a provider.
How to Negotiate:
Review the Contract Carefully: Read the contract thoroughly and make sure you understand all the terms. Pay close attention to reimbursement rates and payment schedules to ensure they align with your agency’s financial goals.
Negotiate Rates (if possible): Some insurers may allow for rate negotiation, particularly if your services are in high demand or you’re one of the few providers in the area. Don’t be afraid to ask for higher rates if you believe they’re justified.
Seek Legal Advice: If you’re unsure about any of the contract terms, consider consulting with a healthcare attorney who can help you negotiate favorable terms and ensure compliance.
Once the contract is signed, you’ll officially be an in-network provider with the insurer and can start seeing patients and billing for services.
Step 6: Maintain Your Credentialing Status
Credentialing doesn’t stop once you’re approved—it’s an ongoing process. Most insurers require re-credentialing every 1 to 3 years to ensure that your agency and staff remain in good standing.
Tips for Maintaining Credentialing:
Keep Licenses and Certifications Current: Make sure that all staff members’ licenses, certifications, and insurance policies are up to date. Insurers will require proof of this during re-credentialing.
Track Expiration Dates: Use a credentialing management system or simple calendar reminders to track when key documents (like insurance policies or professional licenses) need to be renewed.
Notify Insurers of Changes: If there are any changes to your agency’s operations—such as new services offered, changes in ownership, or new staff—make sure to notify the insurers promptly.
Tip: Missing re-credentialing deadlines or failing to keep your information up to date can result in being dropped from an insurance network, which can disrupt your agency’s operations.
Building Strong Relationships with Payers
Beyond just getting credentialed, building a good relationship with insurance payers can help your agency in the long term. Here are some ways to strengthen your ties with insurers:
Communicate Regularly: Stay in touch with your payer representatives to resolve any billing or contract issues quickly.
Be Responsive: If an insurer requests additional information or has questions about your services, respond promptly to maintain a good working relationship.
Maintain High-Quality Care: Insurers value providers who consistently deliver high-quality care. Meeting quality benchmarks can help you negotiate better rates or secure more favorable contract terms over time.
Final Thoughts
Getting credentialed with private insurers is a crucial step for any healthcare agency looking to grow its patient base and ensure consistent revenue. While the process can take time, being organized and proactive can help you navigate the steps smoothly. Once credentialed, you’ll be able to offer services to a broader range of patients while building strong, long-lasting relationships with payers.