Re: Insurance set ups-Credentialing

[Steve Verno]

I love it when an insurance company says to me, If you dont contract with us, we'll send the check to the patient. 

I say, Go ahead.  After this meeting we stop sending claims for your patients.  They can pay 100% of our usual and customary charges at the time of service and send their own claim based on their contract with you and if you send your member the check, we'll; give them 30 days to pay us or we turn them over to the IRS.   

They get indignant but back off. 

[Pay_My_Claims]

No, there are other ways but the carrier isn't going to tell you about it. Usually you can find a service or supply that is not offered or can't be done within your geographical location.. For example I got one of my clients (psychologist) credentialed with a few closed networks because he offers biofeedback and EMDR. I never accept "sorry we are closed" I at least will give it a shot and most times I am successful.

That is our only "leverage" right now with BCBS because we do "custom Rehab" chairs. We are OK being OON with everyone else but BCBS sends check to clients so we are after our accreditation we will try again

[Pay_My_Claims]

I have came into that situation many of times too. BCBS has soooo many different plans that you have to get specifics and call almost every time to make sure you're on a particular plan. It's time consuming, and can be very costly as stated previously!

Some insurances even make you wait until the panel is open, which can take YEARS because there are too many providers within the same degree (MD, DC, etc) within a certain area. The only way you can get into some of these is when and IF a provider drops it, the next on the list gets in!

Yes especially with DME!!!

[Danni R.]

I love when the carrier tells you they have closed networks, they don't tell you what the exceptions are but then you learn Dr. Joe down the street got in because he lights candles during his chiropractic services..  (that's a funny hypothetical)

Linda, I am really starting to look forward to your posts... especially the ones that make me ROFL. You are so funny.

[Danni R.]

Credentialing/Provider Enrollment/Health Insurance contracting... 

Once you were enrolled, you blindly agreed to be paid the BCBS par fee. Our argument was, why should we go through a commercial insurance company to enroll with Medicare, a Federal Program. 
                                                                                                  

And I have a feeling this is where the lawyers were of tremendous help also, aside from all the other issues... it is a valid argument, and just doesn't make sense... it seems contradictory, if that's the right word.

[Steve Verno]

Credentialing/Provider Enrollment/Health Insurance contracting is something I recommend that you leave it in the hands of a skilled lawyer or someone who is trained and experienced.  it can be a full time, long hour position, taking months and up to a year to complete.  You have to stay on top of everything and every step. 

one practice had me just enroll providers with contracted carriers.  here in Florida, that can take 6 months to complete with Medicaid and Medicare.  Medicaid only backdated the effective date about 6 weeks, not 6 months, so many claims went unpaid or denied.

Here, At one time, you had to enroll and obtain a BCBS provider number before enrolling with medicare. THis was because at the time, BCBS ran Florida Medicare. Complaints to CMS stopped that process.  BCBS deemed the enrollment process to be a contracting process.  Once you were enrolled, you blindly agreed to be paid the BCBS par fee.  Our argument was, why should we go through a commercial insurance company to enroll with Medicare, a Federal Program. 

IT can get very confusing and costly to the provider when in the hands of the untrained and unskilled.  Again, leave  it to the lawyers or experts.                                                                                                     

[Steve Verno]

To make a provider par, the provider needs to contract with the insurance company


Credentialing is an insurance company term, how one credentials is per the insurance company.  Its similar to an intense background check.  The credentialing process can take months and depending on the insurance company, they may or may not pay claims during that period. Crednetialing can also be an insurance contract requirement.