For many of us, the only way we can receive medical care is through some kind of insurance. Either through an employer, our parents, COBRA, or a health insurance exchange. If you’re 65 years old, Medicare will help pay your medical bills and some prescription drugs depending on your plan. Without insurance, receiving the health care we need would prove very difficult.

There is another aspect to the relationship between healthcare providers and insurance companies that is less evident to most members of society. The process by which healthcare providers are paid by insurers for the services they provide isn’t as straightforward as sending a bill and receiving payment.

Healthcare providers enter into agreements with insurance companies that define the rules which must be followed in order for services to be paid. And before providers enter into such contracts, they need to be vetted by the insurance company. Whether it’s a clinic, hospital, dentist, licensed massage therapist, or other practice, they need to be credentialed with most insurers before their services are payable according to the in-network benefits of the insurance plan.

Medical Credentialing

Kaiser Permanente is an integrated managed care consortium and offers one of the largest non-profit health care plans in the United States. But they also operate nearly 40 hospitals, more than 700 medical offices, and have more than 300,000 employees, more than 80,000 of which are physicians or nurses.

When you provide plans as well as medical staff, it’s pretty easy to get your patients coverage. But what if you’re a solitary health provider, opening your own practice either out of school or after leaving a larger facility? Being able to accept insurance can either make or break your practice.

The process of credentialing can be difficult and confusing. You went to medical school to help people, not deal with insurance paperwork. But it’s a necessary chore if you want to open your practice to a wider range of patients. It also streamlines the fee schedule, the act of billing, and reimbursement rates.

Start The Process

The insurance credentialing process usually includes verification and examination of different aspects of your practice as well as your background. This information is often self-reported by the practitioner to the Council for Affordable Quality Healthcare. The CAQH is an online resource for insurance companies that want to check the credentials of practitioners.

  • Education/Training/Experience
  • Residency
  • References (via colleagues and/or professors)
  • Medical licensing
  • State registration
  • Federal registration
  • State certification
  • Federal certification
  • Professional liability/malpractice insurance coverage

With this information at their fingertips, insurers can investigate your credentialing application more completely. Once you complete the contracting and credentialing process, you will be free to start billing those insurance companies. You should already have your NPI number, tax ID, and appropriate licensing to begin accepting insurance.

Work With The Credentialing Experts

For more than 25 years, MBA Medical has been helping those in private practice earn their insurance credentials. With our experience, we help you cut down the amount of time spent getting credentialed and establishing an effective date. For the uninitiated, it could take the better part of a year!

We highly recommend beginning the process as soon as possible. As soon as you have a start date for your new practice, contact MBA Medical Services. We’ll make sure the information is entered correctly and smooth out the entire process. We’ll remove the stress and let you concentrate on building your practice.