Ever wonder how much an insurance carrier will offer you if you contract with them? 

You would think this is an easy question however, you will need to go through the entire credentialing process (which could take months) before you have the knowledge you need to make a decision whether to contract with a carrier or not.

So whether you are a struggling intern getting ready to open your own practice or partnership or an established physician wondering if you should contract with a carrier, you need to credential with them first. 

I am not saying that you need to contract. I am saying that your signature is the last detail of contracting and it is at this time that the carrier will share your specific, geologically located, fee schedule.

There are several pros and cons of contracting with an insurance company or a facility. Being part of a network will help build your practice however; you always take a cut in pay. Not contracting with a carrier will limit your patient base so most physicians conclude contracting is the least of the two evils.

So what's the process?
First, I need to share an important tip - Keep all your documents!

You will need all of your diplomas, certifications and registrations, i.e. NPI certificate, medical license, C.V. and many others.  Send me an email and I'll share the entire list.  Keep these documents in a safe place, preferably at home.  Documents left at work tend to get missing and depending on how much you move around, at least some of these documents will be required each time the carriers update your changes. Always having these documents will help create a smooth and timely transition.

Getting Started-Commercial Plans
We now have a national credentialing database that most of our commercial carriers utilize - CAQH.  The database is on-line, along with a fax number to send all the required documents. You may access this site by going to www.caqh.org.  Registration will take 30-45 minutes if you have all the information. However, you are able to save all the information you entered and come back to complete the form at anytime.  Keep in mind, you will create a user name and password and you will need this information each time you login.

After you have entered your personal information, you will be asked what carriers you would like to have access to the database.  If you try to credential with a carrier you do not list within CQRI, they will not be able to access your information. Once all the information is entered and you have selected the carriers to have access, you will be asked to attest that the information given is correct.
 
Important tip-
Each time you change information within the database, you are required to attest that the information is correct.  The attestation requires your signature via faxed to CQRI. If you fail to fax in the attestation, the update will not show to the carriers.

When CQRI registration is complete, you will be given a provider number, keep this number safe.  This will be the first question you will be asked when informing the carriers that you would like to join their network or just credential (given a provider number to submit out-of-network claims).

The next step is a piece of cake
Contact the Carriers that interest you.  Remember, they will have you go through this process before they share your fee schedule, but you are not obligated to any of them until they have your JOHN HANCOCK on the contract.

Most Carriers will ask for your CAQH provider number and will pull what they need from the database.  A few may also request you to complete a form or two.  That's it, now we wait.

Why does it take so long?
The insurance business has become very complicated in the last few years and depending on your specialty, location and the carrier's patient base in your area, the carrier may or may not need or want you. The zip code of your location speaks volumes - If you are the only dermatologist in a 50-mile area, you will get the best rate (fee schedule), if your area is saturated with a dermatologist on every corner, your rate will be minimal, if accepted at all.

The carriers may have 1, 2 or even 3 meetings determining your fate and at one meeting a month it is not unusual to wait 2-3 months to know if you are accepted or not.

When the credentialing is complete and you have been accepted, you will receive a welcome letter, with contact information, contract and fee schedule.

Now the ball is in your court -
Review the contract carefully and make sure you understand their timely filing rules, which keep getting shorter and shorter. Review for carve-outs, procedures that are not reduced, maybe a specific procedure that no one else does in your area (this would be a negotiating tool).  If the payer is historically late in making their payments; look for their promise to pay by date and if they talk about interest payments if paid after a certain amount of days.

Don't forget the fee schedule
The fee schedule is why we are here - no one wants to contract with a carrier to lose money.  If they give codes you do not use, contact the person on the welcome letter and ask for a fee schedule specific to dermatology and/or give them your top 10-20 codes.

Be informed
We need information to make a knowledgeable decision that affects our practices. With the contract in hand and an understanding of the fee schedule they are offering, you will be in a position to make a sound and profitable decision.

Medicare Contracting/Credentialing
Government plans are a little different - no negotiating here and to credential with the government you must contract with them.

Important Tip-
If you credential with Medicare, you should also credential/contract with Retired Railroad Medicare.  Why?  because they are part of the same program.
Example: If a RR Medicare patient calls to make an appointment and you are contracted with Medicare, you MUST see the RR Medicare patient.  However, if you are not contracted with RR Medicare, you are not allowed to bill them.   Ouch!

Medicare has their own form to complete for credentialing -the 855i form. You can find it at www.cms.hhs.gov/cmsforms/downloads/cms855i.pdf .  Complete all sections and provide the documentation requested.  The form is fairly self-explanatory but they also have a staff to help with the application if needed.  Contact your local Medicare office if you need help.

Medicare is also extremely slow; you will want to stay in communication with them in case you are missing information or documentation.  It may take them a month to send you a letter explaining what is needed.  If you call them, they will locate your application and give you status information and a tracking number.  Using the tracking number on follow up calls will help their staff locate your application and provided status in a timely manner.

Important tip
You can begin seeing Medicare patients immediately however, you must hold all claims until Medicare assigns you a Provider number.  The credentialing process can take 30-180 days. If you do not hear from them within 30-45 days, give them a call

Jackie Fowler, CPC-P is the President and CEO of MCR - Medical Claims Resources, Inc. She has 10 years with BCBS and Mailhandlers Benefit Plan (Federal Insurance). Her background is in HIPAA compliance, appeals, project management, training, subrogation and Medicare mandates.
Jackie Fowler
President and CEO
MCR - Medical Claims Resources, Inc
www.mcrbilling.com