There are many important decisions to make when starting a PT, OT, or SLP private practice. One crucial decision is whether to be in or out-of-network with insurance plans offered to members in the practicing area.
Over the years, many of my clients have been practically shut down all because they did not change the business address when they moved or added a location. There is a lot of stress when moving but not changing the business address can directly affect your revenue stream.
Getting your providers or group credentialed and contracted may sound straight-forward but often times it can be anything but. Problems can arise at any point during the credentialing process and if you aren't quick to find the solution, you could find yourself starting from square one.
Let's take a look at some examples of credentialing issues from the beginning to the end of the process so you can learn from other's mistakes.
Jack has experienced a lot of success as a sole proprietor of his business. Jack has had so much success that he is thinking of opening a new location and hiring new therapists. He stops by Diane’s office to discuss the credentialing for his new practice. Jack sits down across from Diane and says, “So I am really excited about this new location, we are signing the lease this week. Hoping to start in about a month.”
Right out of the gate, Diane has some questions for Jack to make sure he is prepared for all the credentialing speed bumps that could come up. “That’s great Jack. Have you gotten your type 2 NPI yet?” Diane asks, the second the question is asked Diane can tell that Jack has become unsure of himself. “A type 2 NPI? No, I don’t think I have one of those” Jack said.
“No problem, you can apply for one online, and they’ll email you one within ten days. But you will need a type 2 NPI in order to credentialing your business as a group provider,” Diane explains to Jack. They then visit the NPPES website and apply for Jack’s type 2 NPI.
Later that week, Diane receives a call from Jack, “I received my type 2 NPI for the business, thanks for letting me know I needed that. Anything else I’ll need before I can begin the credentialing process?” She then goes on to inform him of all of the different things that will need to be in place so his credentialing can go smoothly. Jack couldn’t believe that so many other things had to be in order before he could enroll with different insurances, but he was glad he had a resource to make the process easier.
Penny is the owner of her own physical therapy private practice, and has worked there for over 10 years. Penny wants to start seeing less patients so she can spend more time managing her staff. Her current administrative employee is on vacation for the week so Penny takes it upon herself to make some follow up calls on the credentialing for her newest therapist.
Penny starts by calling Blue Cross Blue Shield, “Good morning, I am looking to get the status of an application that was submitted for a new provider.” She then goes on to give them all of her identifying information, but is surprised when the representative says, “I’m sorry ma’am, that application has been rejected because we requested a copy of the provider’s liability insurance and it was not sent within 30 days.” Penny hangs up and becomes frustrated, now her new employee must wait even longer to start treating Blue Cross Blue Shield patients. When Penny checks the admin email account, she sees there are multiple unread emails from insurance agencies requesting provider information.
When Penny’s admin employee returns from her vacation Penny asks her why these emails were not addressed. The admin employee explains, “With the scheduling of patients, calling on authorization/referrals, and all of the other daily tasks I have, it’s difficult to make time to follow up with the credentialing.” Penny then explains to the employee how important provider credentialing is to getting paid for services provided. While the employee promises to make credentialing more of a priority in her day, Penny’s new therapist still has to wait an extra 60-90 days for the new application to get submitted and approved.
Brittany was extremely prepared when she opened her business, she was organized and thorough. She did all her credentialing herself which was a point of pride for her. Brittany began seeing patients and her billing company began submitting claims. Her billing company explains that the claims are getting rejected at the clearinghouse because she isn’t a provider. “That’s impossible, I have the approval letter right here in front of me,” Brittany explains to the billing rep over the phone. The rep then asks, “Did you put that provider number in the clearinghouse, and get approved to submit electronic claims?” Brittany then pauses for a minute and thinks about the question. “Well no, I didn’t know that was something I had to do. I thought I just got credentialed and I could start submitting claims.”
The rep then goes on to explain that getting set up through the clearinghouse is an important step to the credentialing process, while it doesn’t involve the insurance company directly, it is necessary to send claims and receive payments. Brittany makes a note of this information, so when she hires a new therapist and does their credentialing, she’ll be sure to remember this step.*
The credentialing process is a complex one, that requires accurate applications and rigorous follow up. Outsourcing your practice's credentialing to experts will ensure that your applications are submitted correctly the first time, and follow up is made routinely so you know your application is going to the appropriate channels. To learn more about Account Matters credentialing services, give us a call at 508-422-0231.
Once you begin the credentialing process for your new business, you’ll discover that the insurance companies have a long list of required documents that you will need to submit in order to verify the legitimacy of your business. One of the biggest issues that we run into when credentialing a client is that the information on these documents do not match. That’s where the trouble begins…
CP 575 Form - The CP 575 form is an IRS document that you receive in the mail after you’ve registered for a Tax Identification Number. This form serves as a confirmation of your Tax-ID number and many insurances request a copy. The most important part of this document is how your business name is printed by the IRS. Any application you fill out for your business needs to have the exact same spelling and punctuation as this CP 575 form because if it does not, your application may be sent back because they could not confirm the business name with the IRS. For example, if your CP 575 form says your business name is “Good Health Physical Therapy LLC” you wouldn’t want to fill out a credentialing application with “Good Health Physical Therapy, LLC.” Even though the comma seems inconsequential, insurance companies are extremely thorough and may reject the application.
CAQH Proview Profile - The CAQH Proview Profile is an essential part of the credentialing process. Insurance companies use this to verify the information you have on your insurance specific application. Providers need to update and attest to their CAQH Proview Profile information every quarter, so make sure your primary practice is accurate as well as your license information. If your CAQH is incomplete or inaccurate, your application may be delayed or rejected.
Business License - Some states do not require PT, OT, SLP clinics to have a business license so that should be the first thing you consider when drawing up your business plan. If your state does require a business license, your desired insurances will want to have a copy for their records.
General Liability Insurance - Every provider needs to have their professional liability insurance in place, unless stated otherwise by your employer. But new businesses need to have General Liability Insurance that covers their company. Every insurance that you would ever want to be in-network with will require a copy of your liability insurance. One important thing to remember when signing up for liability insurance is to use the clinics address. Often owners will buy liability insurance before they have an established practice location and use their home address. It doesn’t always cause delays or rejections of credentialing applications, but it is always good to go back and update the address or use the practice location when applying for the liability insurance.
Credentialing requires a lot of documentation, and I mean a lot. But these are a few of the major ones that you will need established before tackling the stack of applications. If you have any credentialing horror stories, please feel free to share them with us. If you would like some advice or assistance with your credentialing, please feel free to reach out, we are more than happy to help. Just call 508-422-0231 or email firstname.lastname@example.org.
Any provider who has attempted the credentialing process knows it is exactly that, a process. Applications are tedious and the follow up with insurances can take countless hours out of your day. One of the most important parts of credentialing is knowing how long the process takes so providers can plan accordingly.
Each insurance company has their own credentialing department and each department has their own process for adding a provider or group to their network. For many insurance companies the process includes: