Finances

Insurance Credentialing: Path to Practice Growth

By Aaron Lech, OD, FAAO

Enhance your insurance credentials to expand options for patients.

In the bustle of an optometric practice it is easy to overlook the basics sometimes–such as making sure you have become credentialed to serve on insurance panels and provide patients with essential services. Here is a primer on why credentialing is important to the growth of your practice and some tips on ensuring you have the contracts you need.

What is CAQH?

The acronym stands for The Council for Affordable Quality Healthcare. The following information about this non-profit organization is featured on its web site, www.caqh.com:
“The CAQH Universal Provider Datasource (UPD) service is the industry standard for collecting provider data used in credentialing, claims processing, quality assurance, emergency response, member services, such as directories and referrals, and more. By streamlining data collection electronically, UPD is reducing duplicative paperwork and millions of dollars of annual administrative costs for more than 960,000 physicians and other health professionals, as well as over 600 participating health plans, hospitals and healthcare organizations.”

Expand Insurance Providers
There are three parts to the insurance equation. They are Applying, Credentialing and Contracting. The latter two can be performed at the same time. Credentialing refers to the process by which an insurance company verifies that you are who you say you are. This would include state license, DEA, Fellowship, etc. Each insurance company verifies these credentials differently. While some may use a more central source such as CAQH [see blue box to the left], others choose to run the verification process in-house and still others (such as a medical group) may credential a set of provider members and shop these to other medical groups or insurance companies.

The business case for credentialing is simple–if you aren’t credentialed, you can’t be offered a contract and you can’t access insurance payments for those patients. My office is credentialed on every medical panel that we wish to be on. While Medicare is typically the first panel providers are credentialed with, others such as Blue Shield, Blue Cross, United Healthcare, Aetna, HealthNet and Cigna may be big players depending on your region. There are smaller national and regional health plans as well.

Possible Per-Patient Revenue Booster
Credentialing is the foundation necessary to receive contracts and ultimately payment for services. This may open doors to get reimbursed for additional services you provide for patients already in your practice or may open the door for referrals from other providers included in the same network. But credentialing does not let you treat any additional conditions. Those permissions are defined by scope of practice laws.

Utilize an Insurance Credentialing Service?

Primary Eyecare Network (PEN) has a new insurance credentialing service that can simplify the process for your practice.

Click HERE to download a PDF detailing this new tool.

ROB Editors.

Set Aside Time and Money to Become Credentialed
When you do it yourself, credentialing can require weeks of time and communication spread over a six-month period, just for one plan. Filling out the six- to 12-page information request can take hours and typically needs to be repeated for multiple plans. This also must be inspected and re-attested every 90 to 180 days for certain plans. Discussions with credentialing specialists at the insurance company that don’t understand optometry can also be time consuming. When you calculate an average amount of time (say four days of time for one plan) X a day rate of $400, it comes to $1,600 per plan. We currently have 10 major insurance companies we have contracts with.

Figure Out ROI of Receiving a Credential
Analysis of the insurance panel contract will tell you whether it is worth your time and money to obtain a contract with a specific insurance company. Without a credentialing vehicle, you can’t get to the analysis stage. If you can submit a credentialing package for six plans at $2,000 total, you are in the position to analyze whether to take the plan and you’ve saved $3,000-$5,000 in expense. You can’t say no (or yes) unless you are credentialed. The insurance plan won’t consider you until they can verify who you are.

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Aaron Lech, OD, FAAO, is a partner of ClearVue Eye Care in Roseville, Calif. To contact him: drlech@clearvue.org

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