Look before you sign: The payer physician credentialing process

In August 2009, the Medical Group Management Association released the results of its annual survey of its members on issues that challenge them the most in their professional lives. In this edition of Practice Makes Perfect, we address No. 17 on the list: Dealing with the commercial-payer physician credentialing process.

The revenue cycle can be affected significantly by credentialing issues. When considering enrollment with commercial payers, many providers overlook the fact that it is not always necessary to join a network or plan. New practices sometimes fall into the category of “sign up for every plan” in order to build their patient base. Before signing up for a commercial plan, consider the following issues:

Does enrollment in the network automatically force me to accept every plan and product at every level?

Ask about the various products and coverage limits of each. Signing an agreement can sometimes mean participation across all lines of business.

What are the advantages to joining this plan?

It may be advantageous to belong to the same networks and plans as your potential referral sources. Specialty practices should check with their referral sources and ask which networks their patients belong to. Many referral sources will provide a snapshot of their payer mix, (percentage by plan, not dollars) to help with participation decisions. This will ensure a smooth referral process, and primary-care practices will appreciate the effort to provide seamless referrals for their patients.

Can I see patients with this insurance without signing a contract, as out-of-network? Are there advantages to remaining out of this network?

Specialty practices may consider the number of practices in the area of the same specialty and compare the networks they participate in to remain competitive. Before signing up, contact the payer and request a sample fee schedule. Ask about coverage limitations, prior authorization processes and out-of-network billing. If their fee schedule is low, it may be a financial risk to participate. Remaining out of network may allow you to bill the patient for your full fee.

What is the enrollment process? Can I enroll through the National Committee for Quality Assurance?

The National Committee for Quality Assurance offers a single application that can be submitted simultaneously to participating insurance plans. Check with the plan to see if they participate in the NCQA before beginning the enrollment process. If the plan does not participate in the NCQA, ask a provider enrollment specialist for assistance.

Many plans require an application request letter to open a file on the practice before they will accept an application. Using a blank application provided to you by a colleague will cost you time, as forms are frequently updated. An out-of-date form will be rejected and returned to you, starting the enrollment process over again.

Nancy Enos

Independently contracted MGMA consultantMGMA Health Care Consulting GroupEnglewood, Colo.