To Credential, Or Not To Credential?
By Andrew Bundy
When a new medical or mental health practice gets started, one of the first things it has to do is work through credentialing.
Credentialing is the first process in getting paid by insurance companies. A new practice has to prove that the providers are who they say they are. It is what allows you to be considered “in-network” or “participating.” Then, the practice signs a contract with the insurance company, making sure that the provider gets paid for their services.
Before a provider decides to go and create his or her own private practice, or a new group of providers want to start their own group practice, knowing a little about credentialing will save a lot of headaches in the future.
What information do I need to start the credentialing process?
When credentialing, imagine that you are back in the interview process to get your first job. Some of the information, such as your licensure and resume, will be the same in this process. Preparing ahead of time like you are preparing for an interview might mean you have more information than you need, but it is better to be overprepared than underprepared.
Aside from that basic information, there are more-specialized pieces of information you will need. While this is not an exhaustive list, these are a few of the pieces that every provider needs to know when embarking on the credentialing process.
First, a provider needs its NPI, or National Provider Identification. There are actually two types of NPIs. The first is the individual, or NPI-1. This is the provider identification for each provider in the practice.
For example, Dr. Brown will have his own NPI while Dr. Crusher has her own. Working together, Brown and Crusher would have to give their individual NPIs. When setting up the practice, the practice itself might get an NPI, known as an NPI-2. When filling out the paperwork, make sure the NPI number is the one that is being requested. Putting an NPI-1 into a field looking for the NPI-2 will slow down the application process.
In addition, each provider will have to give his or her social security number and license number. It is also good to have proof of liability insurance and office phone, fax, email, and address.
Sometimes, a credentialing agency will ask for a crisis number, so it is best to have one handy.
In the age of COVID, credentialing agencies may ask if you plan to offer in-person sessions or telehealth. If the practice is going old-fashioned and not planning on telehealth, then it is fine to say that it does not offer that service. However, more and more people are using telehealth than ever before, so one may need to look into those options. There are many ways to keep information secure, as well as phone and email systems to use for telehealth and general communication purposes.
Keep track of reference numbers
Much of the initial work will be filling out printed-out forms, using PDF forms online, or filling in fields in a computer system. It can be easy to get confused, especially when trying to get credentialed with multiple agencies or insurance. A key to moving through this process is keeping track of the reference numbers.
After completing the initial setup, the system or person on the other end will usually give you a reference number. Create a spreadsheet with this reference number and the information about the credentialing agency. Be sure to put in the date that the form was filled out. Since this process can take time – weeks or months – knowing when the process started can be very useful for tracking the progress of your credential.
Also, if you talk to a person, make sure you get their name. Two months after your initial contact, when the system seems to have lost your information, having a name is far more useful than just saying “I talked to some guy a couple of weeks ago.” And do not be afraid to toss that person under the proverbial bus. If Wesley was in a hurry and said all of your paperwork was in order, but Julian is telling you that you forgot to sign a release two weeks later, Wesley needs to double-check his work better.
Understand institutional differences
Every agency you contact will have its own process. While the information they will need is pretty standard, the way they get that information or the process they use to prove you are who you say you are may be different.
For example, there can be variations in this process. Cigna might require practices to create individual applications for each clinician if the practice is under three providers. Cigna also has a pre-application form that needs to be completed before it allows you to actually apply. Optum, on the other hand, will not credential groups, but each individual provider, but it only has one application.
Also, remember that groups may still prefer handwritten paperwork. Capital Blue Cross, for example, has the provider print out a paper copy of the application, fill it out, scan it back in, and then email or fax it to them.
Another example is Health Advocate EAP, which has everything online through a digital portal. Other providers prefer having the paper copy mailed to them. Double-check the process for every insurance before diving into the application. It may seem tedious, but it will save time in the long run.
But what about Medicare and Medicaid?
In Pennsylvania, Medicare and Medicaid go by many names, such as Gateway or Keystone First. Before going through the process of credentialing through Medicaid or Medicare, be aware that both of those insurances cover different populations and may have additional governmental strings attached.
For example, if you are in-network with Medicaid in Pennsylvania, it is more difficult for a patient to self-pay for your services. If you are not a participating provider with Medicaid, there is no issue with patients choosing your service and paying themselves. In all cases, the self-pay agreement must be made upfront before the initial meeting, and it might be a good practice to create a form saying that this is a mutual agreement between the provider and the patient that self-pay has been chosen.
For Medicare, the provider’s credentials are very important. Medicare requires the provider to be a licensed clinical social worker (LCSW) to be eligible to bill for services. Also, be aware that if you are credentialed through Medicare or Medicaid, you need to offer that person an appointment within seven days of the initial contact. Failure to do so may impact compensation.
Be sure to check with your state’s Department of Health or Department of Human Services, such as the one in Pennsylvania, for more information about what the state allows.
That sounds like a lot of work
In some cases, it can take up to six months to complete a credentialing process. Because of this hassle, many therapy offices are 100% self-pay. They do not accept insurances because it is much simpler to bill a client for their services.
However, some insurances will link to your practice on their website. Others will recommend you through services like employee assistance programs (EAPs). If the goal is to reach the most people as possible in your community, then working with insurance is inevitable.
If you have decided that you will begin the credentialing process, you may be on hold for a long time. There may be a back-and-forth between you and the credentialing agent, filling out forms, double-checking social security numbers, and making sure everything is in place before the contract is signed. That brings you to an important question, “How much is my time worth?”
Credentialing is a service that online companies can charge hundreds of dollars for. It is also a job that a mental health virtual assistant can do. The time you spend dealing with credentialing is less time you can spend counseling people. In a busy mental health practice, this could result in fewer slots for new patients.
In the end, only you know what is best for your practice. But the exposure and referrals you can get by being credentialed may be worth the time and money.
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