Q: What Is Credentialing? Do I have to be credentialed to bill health insurance?
In simple terms, credentialing is like "registering" with a health insurance company. Once you are credentialed, you are "in network" with the payor. They verify the information you provide, which ensures that they have quality providers in their network. If a patient has out of network benefits, you may still bill the insurance if you are not credentialed, but the member will have higher out of pocket costs. Paraprofoessionals (RBTs, technicians) do not need to be credentialed with most payors (there are some exceptions). BCBAs, SLPs, OTs, LCSWs, LPCs, LMFTs and other professionally licensed/certified providers will need to be credentialed.
Q: What is Contracting?
Contracting is the formal process of legally agreeing to service terms and remibursment rates with a health insurance company. You must agree to a contract in order to proceed with the credentialing process. Some companies do this process in tandem with credentialing, while others execute the legal contract first and then require you (and the other providers in your group) to be credentialed (or registered) under that contract. Each payor has their own process and sequence of events. Contracts may be obtained under an individual provider or a provider group (using the Tax ID and NPI for the clinic).
Q: How Long Does Contracting and Credentialing Take?
The entire process of contracting with an insurance company and then becoming credentialed can take a year or more, though 6 months is average. Once you have a contract, credentialing additional providers under that contract generally takes 60-180 days. Some insurance companies have faster timelines than others. Somtimes, payors complete the credentialing process faster than their stated timeframe, but that depends solely on the payor's efforts.
Q: What Do I Need Before I Can Start the Contracting and Credentialing Process?
If you are a BCBA or other professional provider seeking credentialing, you will need a current and up-to-date CAQH profile and NPI. CAQH is a database that houses provider information - Insurance companies access this for validation of your information. An NPI is a National Provider Identifier - a number assigned to you for billing purposes. TLC Credentialing and Consulting provides training on obtaining an NPI and setting up your CAQH profile. Contact us today!
Some payors have additional requirements as well - like site visits, fingerprinting or background checks.
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Q: Can I negotiate my rates with the insurance company?
Yes, you can, however, many payors will not entertain negotiations until you have been contracted with them for a minimum of 1 year. Additionally, it is best to enter into a rate negotiation when you have data to present regarding successful clinical outcomes. TLC Credentialing and Consulting can advise if the rates you are being offered upon initial contracting are reasonable and customary. We can also provide tips on entering into rate negotiations with a payor.