Insurance Contracting – Get Credentialed & Sign Insurance Contracts with Major Insurance Companies

Once you are credentialed, the next step is contracting with insurance companies. This involves signing contracts that outline the terms of your participation, reimbursement rates, and billing procedures.

Insurance Contracting

Steps for Insurance Contracting

  • Review: Carefully review the terms and conditions of the contract. Pay close attention to reimbursement rates, billing procedures, and any obligations you must meet.
  • Negotiate Terms: If necessary, negotiate the terms of the contract. This can include reimbursement rates and other key aspects of your agreement with the insurance company.
  • Sign the Contract: Once you are satisfied with the terms, sign the contract and return it to the insurance company. Make sure to keep a copy for your records.
  • Implement Contract Terms: Ensure that your practice management system and billing processes are aligned with the terms of the contract. This may involve updating your billing software and training staff on new procedures.

By successfully completing the credentialing and contracting process, you will be positioned to accept insurance, expanding your client base and increasing your revenue potential. For more detailed guidance and support, join our “Insurance Reimbursement Program” and streamline your path to becoming an in-network provider.

the Credentialing & Contracting Process

The next step is to get credentialed with insurance companies and sign contracts. This process can vary slightly between insurers, but the general steps are similar. Here’s a comprehensive guide:

  1. Preparation:
    • Gather all necessary documentation (e.g., NPI number, medical license, malpractice insurance, CV/resume, board certifications, DEA certificate).
    • Ensure your CAQH ProView profile is complete and up-to-date if applicable.
  2. Choosing Insurance Companies:
    • Decide which insurance companies you want to work with (e.g., Aetna, Medicare, Blue Cross Blue Shield). We suggest starting with 3 big names insurance companies in your states.
    • Research their credentialing processes and requirements.
  3. Application Submission:
    • Complete and submit credentialing applications to each insurance company.
    • Provide all required information accurately to avoid delays.
  4. Follow-Up:
    • Regularly follow up with the insurance companies to check the status of your application.
    • Be prepared to provide additional information or clarification if requested.
  5. Contract Review and Negotiation:
    • Once approved, review the contract terms carefully.
    • Negotiate terms if necessary to ensure they are favorable for your practice.
  6. Signing the Contract:
    • Sign the contract and return it to the insurance company.
    • Retain a copy for your records.

Detailed Steps for Major Insurance Companies

Aetna

  1. Initial Contact:
    • Visit the Aetna Provider website: https://extaz-oci.aetna.com/pocui/
    • Find the contact information for provider relations or use their online form to express your interest in becoming a network provider.
  2. Application Submission:
    • Complete the online credentialing application or download and submit the required forms.
    • Ensure your CAQH ProView profile is up-to-date, as Aetna may use this for credentialing.
  3. Follow-Up:
    • Monitor your email and CAQH ProView for updates.
    • Follow up with Aetna’s provider relations department if needed.
  4. Contract Review:
    • Review the terms of the contract provided by Aetna.
    • Negotiate any terms if necessary.
  5. Signing the Contract:
    • Sign the contract and return it as instructed.

Blue Cross Blue Shield

  1. Initial Contact:
    • Visit the Blue Cross Blue Shield Association website and navigate to the provider section: https://provider.bcbs.com
    • Choose your state’s Blue Cross Blue Shield plan.
  2. Application Submission:
    • Complete the credentialing application as per your local Blue Cross Blue Shield plan’s instructions.
    • Submit all required documentation, ensuring your CAQH ProView profile is complete.
  3. Follow-Up:
    • Monitor your application status via the Blue Cross Blue Shield provider portal or contact provider relations.
  4. Contract Review:
    • Review the contract terms provided by Blue Cross Blue Shield.
    • Negotiate any unfavorable terms if necessary.
  5. Signing the Contract:
    • Sign the contract and return it as instructed.

UnitedHealthcare

  1. Initial Contact:
  2. Application Submission:
    • Complete the credentialing application and submit it along with all required documentation.
    • Ensure your CAQH ProView profile is current.
  3. Follow-Up:
    • Check your application status through the UnitedHealthcare provider portal.
    • Follow up with provider relations if needed.
  4. Contract Review:
    • Review the terms of the contract from UnitedHealthcare.
    • Negotiate terms if necessary.
  5. Signing the Contract:
    • Sign the contract and return it as instructed.

Determine Which Insurance Companies to Apply for Credentialing Based on Your State

Research and Identification

  1. Identify Major Insurers in Your State:
    • Visit your state’s Department of Insurance website for a list of licensed insurers.
    • Search for the major insurers that cover a significant portion of the population (e.g., Aetna, Blue Cross Blue Shield, Cigna, UnitedHealthcare, Humana).
  2. Check Total Market Share:
  3. Consult with Local Medical Associations:
    • Contact local medical societies or associations for recommendations on which insurers are commonly used by providers.
  4. Consider Patient Demographics:
    • Analyze your current and potential patient base to see which insurers they use.
    • Conduct surveys or gather data during patient visits.
  5. Peer Consultation:
    • Speak with colleagues in your field to get their experiences and recommendations.

State-Specific Resources

  1. Department of Insurance Website:
  2. State Medical Associations:

Build an Insurance Provider Number Database

Why Maintain a Provider Number Database?

  1. Efficient Claims Submission:
    • Accurate provider numbers ensure that claims are processed correctly and promptly.
    • Avoid denials and delays due to incorrect or outdated information.
  2. Credentialing Management:
    • Keep track of all credentials and renewal dates.
    • Facilitate easy updates and verifications.
  3. Compliance:
    • Ensure adherence to insurer and regulatory requirements.
    • Maintain accurate records for audits and inspections.
  4. Practice Expansion:
    • Simplify the process of adding new providers or locations to your practice.
    • Ensure seamless integration into existing billing systems.

Building Your Database

  1. Information to Include:
    • NPI Type 1 and Type 2 numbers.
    • State license numbers and expiration dates.
    • DEA numbers.
    • Insurance provider numbers for each insurer.
    • CAQH ID and login information.
    • Renewal and revalidation dates.
  2. Tools for Database Management:
    • Spreadsheet Software: Use Excel or Google Sheets for simplicity.
    • Practice Management Software: Consider software that integrates with your EHR and billing systems.
    • Credentialing Services: Third-party services can manage and update your database.
  3. Regular Updates:
    • Schedule regular reviews and updates of your database.
    • Assign a staff member to manage and maintain the database.

Evaluate an Insurance Contract & Fee Schedule

Reviewing the Contract

  1. Key Sections to Review:
    • Reimbursement Rates: Compare the rates offered for common services and procedures.
    • Payment Terms: Understand the payment schedule and any conditions for reimbursement.
    • Obligations and Requirements: Review provider responsibilities, documentation requirements, and compliance standards.
    • Termination Clauses: Know the conditions under which the contract can be terminated by either party.
    • Dispute Resolution: Understand the process for resolving payment disputes or other issues.
  2. Fee Schedule Evaluation:
    • Compare with Medicare Rates: Use Medicare’s fee schedule as a benchmark.
    • Assess Service-Specific Rates: Ensure the rates for frequently performed services are adequate.
    • Evaluate Adjustments and Updates: Know how and when fee schedules are updated.
  3. Legal and Financial Review:
    • Legal Consultation: Have a healthcare attorney review the contract.
    • Financial Analysis: Consult with a financial advisor or accountant to assess the financial impact.

Successfully Appeal to Closed Networks & Become an In-Network Provider

Understand the Reasons for Network Closure

  1. Capacity Issues:
    • Insurers may close networks when they have enough providers to meet demand.
  2. Specialty Saturation:
    • Networks may be closed to specific specialties that are already well-represented.

Crafting a Successful Appeal

  1. Gather Supporting Data:
    • Patient Demand: Provide evidence of patient need and demand for your services.
    • Unique Services: Highlight any unique services or specialties you offer.
    • Geographic Need: Emphasize your location and the accessibility benefits to patients.
  2. Write a Compelling Appeal Letter:
    • Introduction: Clearly state your request to join the network.
    • Supporting Data: Include the data gathered, focusing on patient benefits and needs.
    • Professional Qualifications: Highlight your qualifications, experience, and any special recognitions.
    • Community Involvement: Mention any involvement in the local healthcare community or initiatives.
  3. Submit and Follow-Up:
    • Send your appeal to the provider relations department.
    • Follow up regularly and be prepared to provide additional information if requested.

Timeline for Getting Contracts

Typical Timeframes

  1. Initial Contact to Application Submission:
    • 1-2 weeks: Research and gather required information.
    • 1-2 weeks: Complete and submit applications.
  2. Application Processing:
    • 30-60 days: Credentialing process and initial review by insurers.
  3. Follow-Up and Negotiation:
    • 30-60 days: Follow up with insurers, address any additional requests, and negotiate terms.
  4. Final Contracting:
    • 1-2 weeks: Review and sign the contract.

Managing Expectations

  1. Typical Total Duration:
    • 60-90 days from initial contact to final contracting.
  2. Delays and Variations:
    • Be prepared for potential delays due to additional information requests, site visits, or high application volumes.

Continue Learning

Continue learning about insurance reimbursement best practices, growing your medical private practice revenue, researching ICD 10 codes, and much more:

Insurance Contracting

Legal Disclaimer & Affiliate Disclaimer

We are paid affiliate commissions, referral fees, or we may receive other considerations, any time you purchase any third-party products or services through this Website. https://growoffline.com/terms

All content contains personal experiences and is not intended to provide medical advice. For personalized medical guidance, please consult with a qualified healthcare professional. The author and associated entities assume no liability for actions taken based on the content herein.