Monthly Archives: January 2011

Insurance Credentialing for Physicians

Time and again new practices invest countless hours and money focused on office space, equipment, software and staffing only to open their doors for business and find significant delays in getting adequate insurance reimbursements. More often than not, the problem could’ve be allayed by addressing the insurance credentialing process early and thoroughly – creating the necessary relationships with insurance carriers. Here are a few considerations to keep in mind as you address the insurance credentialing process.

Timing – Start Early!

Plan on starting the insurance credentialing process early – at minimum allow at least 6 months before you see your first patient. Carriers will often take as much as 3-4 months to review documents and make a determination, even if everything is in order, though it is known to take up to 12 months. If there are errors, missing information or a question about submitted documentation, several more weeks or even months can be added to the process. This 6 month allowance, starting from the time credentials are submitted, usually gives enough time to address problems should they arise. If too little time is granted before the practice opens, and you begin seeing patients before insurance credentialing is complete, you are open to the risk of getting an “Out-of-Network” rate, reimbursements might be sent to the patient, or, worst case scenario, you may not get paid at all.

Identify Target Carriers

To define which insurances you might credential with, consider your practice location and patient demographics. Will a significant percentage have Medicare or Medicaid? Is there a particular company or business in the area that employs a large portion of the surrounding population? A quick call to their human resources office to inquire what insurances they currently offer employees (as well as possible changes the near future) can be a good indicator of the carriers you’ll want to consider.  Also, check with colleagues, other providers, clinics and even larger hospitals in the area and ask who their most common payors are. Inquire about which payors are best to work with – who reimburses in a timely manner, which offer the largest enrollment, and which carriers might be at capacity with other providers in your specialty.

Contact Insurance Carriers

With your list, contact each of the provider services offices of each of your target carriers. One of your first questions might be to ask if they are accepting new practices in your specialty in your area. More often than not there’s no problem here, but don’t be discouraged if they say no – just keep moving down the list and prepare to check back with them later for an opening.   If the carrier is receptive to new providers, make sure you get all pertinent information about the process – i.e. names, addresses, phone numbers, timing, required forms, and so on. Don’t forget to ask about online submission too, as many carriers today allow you to provide all information online and mail in the supporting documentation.

Submitting Credentials

Now that you’ve completed your research and identified which insurance carriers you’re going to file with, you’ll need to compile and submit all of your information. Most will generally require you provide the following:

• Updated resume

• Personal demographic information

• Practice and business information

• State and federal DEA numbers

• State licensing and registration information

• Evidence of education – i.e. Diploma certificate

• Malpractice insurance information

• Information on any disciplinary actions

While this can be a lot, there is some good news – since most carriers ask for the same information, once the first submission is complete, you can just transcribe all the details from one form to the next. You will also benefit enormously in the future by storing copies of these documents in a safe place. As your practice matures and you seek to credential with other insurances, you’ll have this same repository of information readily available.

Once you’ve completed the application, don’t forget to double-check everything. In fact triple check it and have someone else look over it as well. Don’t expect carriers to correct an obvious mistake for you – it’s not their responsibility, and, frankly, they just won’t. The importance of double and triple checking cannot be stressed enough as the entire process can be held up by a month or more from the slightest mistake.

Finally, after your information has been submitted, allow an appropriate amount of time (1-2 weeks for mailed submissions) and follow-up with the provider services office to confirm receipt. If you were able to obtain a contact name in your early research call them directly. Once receipt is confirmed don’t hesitate to follow-up again in say, 3-4 weeks to see if they’ve reviewed it yet or if they found any problems. If everything’s on track, plan on checking back in another 3-4 weeks until the process is complete. This can save a lot of turnaround time if you can learn over the phone there was some sort of hold up. As alluded to above, expect this part of the process to take several months – credentialing offices are often centralized and may be reviewing hundreds of submissions for many different areas at any given time. If there’s no movement after several months, you consider stepping up your calls to a weekly basis.

Hopefully your hard work and phone calls has paid off and you’ve made it through the insurance credentialing process in just a few short months.

Here are a couple of shortcuts to credentialing not mentioned above:

  • Hire professional assistance ~ There are many different organizations that can help with the insurance credentialing process. If you’ve contracted with a practice management company this process is often covered already. If you’re considering a medical billing company to manage your insurance and patient billing they certainly should have the experience with carriers to provide at least some guidance, if not manage the process for you. Also, there are a few professional insurance credentialing companies that specialize in this process for new practices but they can often come at a high price.
  • CAQH ~ The Council for Affordable Quality Healthcare has developed an online service intended to eliminate the need for multiple insurance credentialing submissions. In short, you complete one form for all of their participating insurance carriers and you authorize who will receive your information. The CAQH Universal Credentialing DataSource is located at:


The insurance credentialing process is critical to getting your practice off to a good start – and ensuring a quicker transition to profitability. While it can be time-consuming, an early start will give you the chance to address problems should they arise. Just be patient and keep these tips in mind and you’ll get through it:

• Start early – expect the process to take up to 6 months

• Choose a target list – don’t try for every carrier out there, you can always expand your list later

• Double check your work before you send it in

• Follow up regularly and keep the process moving

• Don’t be overwhelmed – it’s just paperwork


“Sometimes when you innovate, you make mistakes. It is best to admit them quickly, and get on with improving your other innovations.”  -Steve Jobs

Cowtown Netweavers 01.26.2011

Today, I was the one who had the opportunity to give my presentation at Cowtown Netweavers for our meeting.  I spoke on what services Medical Account Solutions provides and gave everyone a bit of education on the process. I am really passionate about what I do and was very inspired by all the questions that people had.  I particularly wantContinue Reading

My Story: how I got into Medical Billing

My name is Misty Gilbert and I have been in the medical field for 15 years.  My experience in the medical billing industry comes from working in doctor’s offices and with my client’s. I took my first job with a Dermatology office in California, March 1996.  I was hired as a part-time File Clerk and only workedContinue Reading


“Real riches are the riches possessed inside.”  -B C Forbes

The Surprising Truth about What Motivates Us

Our motivations are unbelievably interesting.  We are not as endlessly manipulable & predictable as you would think!  Reward or punish?  This is the typical motivational scheme.  Once you get above rudimentary cognitive skill, rewards don’t work that way.  For simple straight forward tasks…if you do this then you get that, this is great!  But when aContinue Reading


“Our work is the presentation of our capabilities.”  -Edward Gibbon

Setting Goals that Work

The plans of the diligent lead surely to plenty, but those of everyone who is hasty, surely to poverty. – Proverbs 21:5 “Are you a goal setter? Do you typically set goals at the first of the year? If not, why not? Goals give you a starting point and a destination. It is the easiestContinue Reading

Keys to Achieving Your Goals

Another year and another set of resolutions. If you’re like most Americans, you’ll probably forget your goals by mid-February. So how do you make your resolutions actually happen this year? First, keep in mind that goals are dreams; but don’t stop at just dreaming. Turn your dreams into bite-sized pieces that will gradually create aContinue Reading


“Obstacles are those frightful things you see when you take your eyes off your goal.”   -Henry Ford