There are many important considerations when starting a new practice or entering into a new payer agreement that need to be taken into consideration. Knowing when to start the hospital or insurance payer credentialing process is essential to proactively assuring timely reimbursements are flowing into a medical practice. Yet, it is often one of the most misunderstood and neglected administrative processes, resulting in lost revenue from patients being seen prior to the physician/practice receiving confirmation of approved status.
For the new physician-graduate, the first step in identifying when to start the credentialing process is before post-graduate training has concluded, but after determining whether or not to be independent or an employed physician. Employed physicians are typically guided through the credentialing process with the hospital/health system through the Recruitment, Medical Staff Services and Provider Enrollment areas. The independent physician, however, will need to determine which hospital/health system he/she wishes to align with, if any, and begin the hospital/health system’s credentialing and privileging process. Depending on the specialty of the physician, clinical privileges at a hospital, or a documented plan as to how inpatients will be admitted and followed, is required to participate with various insurance payers. As a result, the hospital credentialing and privileging process should commence at least 3-4 months prior to the conclusion of post-graduate training.
Another major consideration is which payers to participate with. An effective method to answer this question can be obtained by proactively identifying the payers that represent the highest percentage of volume a practice’s geographic patient population. This assessment will help determine which insurance payers should be focused on, so the insurance credentialing process can be initiated. Generally speaking, this exercise will result in four or five major insurance payers that provide the highest degree of revenue to the medical practice.1 Many, but not all, insurance payers utilize the CAQH national web-based credentialing application repository to facilitate credentialing with their Plan. In order to gain access to the CAQH, physicians must be ‘sponsored’ by a participating Plan to gain access to CAQH and from there can authorize additional insurance payers to access their credentialing information. Note that it is recommended that each insurance payer be queried regarding their credentialing process so any participation delays can be mitigated.
It is essential to ensure approval notifications of hospital credentialing/privileging and insurance payer credentialing are received before seeing patients in the hospital or billing payers for services. Hospitals and insurance payers are required, by law and/or various accreditation standards, to notify physicians of credentialing approvals. In the event more than 3 months has passed and the approval notice has not been received, it is recommended that physicians reach out to the hospital/health system or insurance payer to determine the status of their credentialing.