In today’s health insurance market, having Insurance Credentialing is crucial to the success of your practice. Health insurance credentialing is a procedure that most medical health insurance providers utilize for you to be accepted into their network. Your practice can get an appraisal of its risk by being evaluated about its medical history, organizational structure, financial stability, and legal status. When this happens, your practice can be assured that it is receiving the appropriate premium rate.

Insurance companies employ certain processes to ensure they pay out enough money to pay claims that their insureds have submitted. One of those steps is becoming affiliated with an insurance credentialing firm. Some suggest that becoming affiliated instead of purchasing insurance is more difficult and time-consuming. That suggestion, however, should not be taken seriously. Being affiliated does take more work than purchasing, but you will save a lot of time and hassle if you are already enrolled in the plan you want to use. You can use all that extra time to focus on other areas of your practice.

How is the medical credentialing process carried out? First, you will need to find a qualified and licensed insurance provider. You can ask your doctor for referrals, but if they are not available or if your physicians feel your referrals are unreliable, you may try to get a second opinion from another primary care physician. You can also ask your office staff for names of potential providers. Once you have several names of potential providers, call each one and ask them about their particular practices and the insurance credentialing process they go through.

Once you have found a list of potential providers, you will need to schedule an appointment with the primary physician and/or the healthcare professionals who will be reviewing your medical records. You will want to ask about the length of time the provider has been in business, and the number of complaints filed against them, and how many cases have been resolved successfully. If you already know the practitioner’s track record, you can skip this step and ask about their insurance credentialing process. If you don’t know what to expect, prepare for some surprises!

Next, you will discuss whether the private practice provider you have selected will participate in the private practice insurance credentialing program. Some healthcare facilities prefer not to because it lowers their overall revenue cycle by not offering services in all markets. Other insurance companies have been known to exclude certain services from private practice. Know the facility’s revenue cycle before deciding whether or not it will benefit your patients and business opportunity to be included.

If you have decided to become affiliated with a health maintenance organization, you will be submitting claims for care provided by your primary care physicians and staff to the insurance company. If you have chosen to be an independent provider, you will submit claims directly to the Medicare or Medicaid provider. Regardless of which option you choose, becoming affiliated with a PPO is an important part of the medical credentialing process. Whether you decide to become affiliated with a PPO or not, understanding some of the considerations for submission will help you understand your submission.

When performing the medical credentialing process, insurance credentialing agencies consider several things: whether the physician is board-certified, their specialty, size of practice, location, and whether they accept most insurance coverage. While becoming board certified does not guarantee that a provider will be credentialed, being board-certified does reduce the risk of fraud and scams. To be accepted by a provider network, providers must be accredited by the American Board of Medical Specialties (ABMS).

As you can see, the insurance credentialing process can be difficult, time-consuming, and complicated. Fortunately, there are many options and resources available to help healthcare providers to navigate this often complicated environment. As your organization becomes more integrated and your physician’s encounters across different platforms increase, you should become familiar with the insurance credentialing process and be familiar with the terms and tools used by the provider credentialing organizations to determine your level of competence. Being aware of the considerations used in the determination of your healthcare provider status and understanding what type of documentation you need to meet them helps you make the right decisions regarding your professional future.