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Medical Credentialing, Insurance Credentialing, Provider Enrollment

Medical Credentialing, Insurance Credentialing and Primary source verification.

It was only a couple decades ago that healthcare professionals considered medical credentialing-that is, the process of getting enrolled in an insurance company’s preferred provider network-to be an optional step in building their medical practices, or an unnecessary step to growing their client or patient caseloads.

Back then, persons didn’t expect every healthcare provider to accept their insurance (some corners of the healthcare industry, like mental health services, weren’t even covered by most insurance plans). Also, any patients had “out of network benefits,” which meant that the patient could meet with a doctor of his/her choice and then file for reimbursement from his/her insurance company later. Oh How Things Have Changed.

Today, it’s become more necessary than ever for physicians and healthcare providers many types (including chiropractors, nurses, psychologists, professional counselors, and many others) to be in network (AKA “medical credentialing”) with insurance companies. This is a necessity, in part, because more people in the United States have health insurance than ever before. And it’s a necessity because people today demand that their healthcare providers accept their insurance. Put bluntly, if you’re not in network with a potential patient’s health insurance plan, you’re at risk of losing that potential patient to a competing practice.

Medical Credentialing: Important for Growing a Practice

Medical Credentialing (sometimes referred to as “insurance credentialing” or “provider enrollment”) is [https://denmaar.com/mental-health-medical-billing-services/ mental health billing] the process of becoming affiliated with an insurance company so that you (the medical provider) can accept third party reimbursement.

While important for the success of a clinical practice, “getting credentialed” on insurance panels is often an unwelcome distraction from providing quality care to patients. Enrollment applications can be 30+ pages long, and to ensure smooth processing there’s a lot of necessary, time consuming, follow-up.

Our medical credentialing service exists to take the hassle out of getting “in network” with insurance panels. We also offer Expert Medical Credentialing for Nurses, Doctors and Physicians. Find out more about Nurse Credentialing and Doctor/Physician Credentialing.

The Largest Insurance Plans in the USA

There are a few ways to calculate which are the the biggest insurance companies in the United States. Value of the company, lives covered, company revenue… regardless of how you calculate who’s the biggest, some of the names appear again and again. These are the 800 pound gorillas. These are the insurance companies you very likely will want to work with.

According to 2018 data from the NAIC, Insurance Business America listed the 10 biggest health insurance groups in the U.S. They are:

1. UnitedHealth Group: $156.9 billion, Market share: 14.2 percent

2. Kaiser Foundation: $93.2 billion, Market share: 8.5 percent

3. Anthem: $67.2 billion, Market share: 6.1 percent

4. Humana: $56 billion, Market share: 5.1 percent

5. CVS Health (Aetna, Coventry): $55.4 billion, Market share: 5.0 percent

6. Health Care Service Corp: $36.9 billion, Market share: 3.4 percent

7. Centene Corp: $36.3 billion, Market share: 3.3 percent

8. Cigna: $29.3 billion, Market share: 2.7 percent

9. WellCare Health Plans (Centene): $20.5 billion, Market Share: 1.9 percent

10. Molina Healthcare: $18.5 billion, Market share: 1.7 percent

Insurance Plans Today Cover More (pre-existing conditions, mental health and many others)

While in some ways insurance plans are more limited than in the past years (with HMOs and the lack of out-of-network benefits), in other ways patient’s insurance plans are much more robust.

Medical credentialing has become more important as health insurance plans have become broader in regards to the scope of services they cover. These changes include Mental Health and Behavioral Health parity (see the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA)), less restrictions on pre-existing conditions (according to healthcare.gov “All Marketplace plans must cover treatment for pre-existing medical conditions. No insurance plan can reject you, charge you more, or refuse to pay for essential health benefits for any condition you had before your coverage started. Once you’re enrolled, the plan can’t deny you coverage or raise your rates based only on your health.”), and even the coverage of supplemental services such as physical therapy, massage therapy, acupuncture and some holistic medical services.

Insurance Panels: Filling and Closing

Unfortunately for some, insurance panels (that is, preferred provider networks) are becoming increasingly full, meaning the process of getting on insurance panels is becoming more difficult everyday as insurance companies close provider networks and make the barrier for physicians, counselors or any health professionals higher and more difficult to climb.

**That being said, some panels that claim to be “closed” are really just being highly selective about which providers they are adding. Knowing how to position one’s experience and practice can go a long way when it comes to getting into “closed” panels.**

An Insurance and Medical Credentialing Service Can Help

This website provides helpful articles, videos, and tips about how to get credentialed with insurance companies. Alternately, if you’re looking for a medical credentialing service that can take the burden of credentialing off of your plate, we can do that too.

There are few things in life and business that truly pay for themselves. We’ve set our prices to be affordable, so much so that if you turn just one potential patient away-just one-you would have been better financially having us help you with your medical credentialing. The value of just one client or patient greatly outweighs the cost of medical credentialing.

We’d love to talk with you! Call us at 1-855-664-5154.

How Long Does the Medical Credentialing Process take?

The process of getting on insurance panels (if you’re taking a DIY approach) can be both challenging and lengthy. It generally takes between 3-4 months to submit the necessary paperwork, tender supplementary documentation, and correspond with insurance companies’ credentialing departments, before getting approved to join an insurance panel. However, at times the process can move along much faster. For example, Employee Assistant Programs (EAPs) tend to process in as little as 4 weeks. However, on the other hand, if an insurance company is running behind, or if there’s a problem with a physician’s/healthcare provider’s application, the medical credentialing process could take even longer than 4 months.