Health plans, or insurers, create networks of participating physicians, hospitals, labs, radiology facilities and other medical providers. These networks offer services to their members. Unlike hospitals, health plans do not grant privileges to physicians. However, the National Commission for Quality Assurance (NCQA) sets standards for credentialing physicians to join the health plan’s network. NCQA requires primary source verification of numerous physician credentials.

Insurers verify several background items when credentialing physicians for their networks, including:
 

• Education
• Training
• License(s)
• DEA
• CDS (if applicable)
• Board Certification
• Insurance Coverage
• Work History
• Medicare/ Medicaid Sanctions
• Malpractice Claims History

The insurer’s Credentialing Committee approves the physician based on the network need and the physician’s credentials. After primary verification, the health plan’s credentialing committee approves them for joining the network. A summary of health plan credentialing process includes:
 

1. Submit physician application and documentation to health plan

2. Health plan conducts primary source verification (All licenses (state, DEA, CDS), education, training (internship, residency, fellowship), current and previous hospital staff privileges, malpractice insurance coverage (for at least five years), claim(s) history (for five to 10 years), work history (since finishing training), any sanctions with Medicare or Medicaid)

3. Health plan’s credentials committee reviews and approves

4. If required, health plan conducts site visit to physician location(s)

5. Health plan contracts with physician or adds physician to group contract (This can take place before the credentialing process is started or after it is completed – that is determined by the health plan.)

6. Health plan adds physician location(s) and tax ID numbers to billing system

7. Physician joins health plan network

All physician data, such as office locations, tax identification numbers and specialties, must be accurate before being added to the health plan’s billing system. If this information is wrong, you’ll end up with unpaid claims. For example, the system links physician specialties to CPT® payment codes. The health plan provides an approved codes list to each credentialed physician. If a physician submits a claim for a code not on the approved list, the claim will not be paid. In addition, all locations where the physician provides care must be in the system. If the physician submits a claim for patient care at a location not in the health plan’s system for that physician, the claim will be rejected.

The credentialing process for health plans can take two to six months to complete for each physician. In addition, health plans may require site visits by a provider relations representative before a location is added to their system. If you add both a new physician and location, you should do these processes at the same time.

Some useful advice for health plan credentialing:

• Maintain copies of your health plan contracts and review all fee schedules. Don’t sign any contracts until you are sure the claims payments will cover your costs and provide the necessary revenue to meet your financial goals. Analyze all fee schedules before you start the credentialing process. You may decide it’s more advantageous to stay out of a particular network. If that’s the case, make sure you communicate this with your patients since their co-pay will be higher.

• Your initial credentialing application needs to include all locations where you’ll see patients. If it doesn’t and you submit a claim for a location not in the health plan’s system, it will be denied or paid as out-of-network. If you add a location or move a location, you need to update this information with the insurers and health plans prior to submitting claims from any new locations.
 

• Review your claims denials on an aggregate basis as well as case-by-case. You can stop continuing denials if you catch a “macro” error quickly. For example, if most claim denials result from inactive provider numbers, that issue needs to be resolved before additional claims are submitted.

• Claims submissions, either by paper or electronic means, must follow strict submission guidelines to be paid. Therefore, correct numbers must be placed in all the appropriate fields before submission. If inaccurate information is submitted, your staff will be struggling with provider relations, the clearinghouses, your software vendor and the claims payment areas over unpaid claims.

With a little effort, you can control the number of rejected claims because of credentialing errors. If you keep in mind the suggestions listed above, you’ll maneuver through this tedious process much easier and without it costing you unpaid claims.