Conquering Credentialing: What PTs, OTs, and SLPs Need to Know About Insurance Enrollment

Going into business for yourself means financial freedom and the ability to be your own boss. Of course, being in charge means contending with all the ongoing logistical challenges of running a therapy practice—including ensuring that all of your treating therapists are credentialed with all of your major payers. Otherwise, you leave your practice vulnerable to denied claims—and thus, reduced cash-flow. With that in mind, here’s the 4-1-1 on credentialing.

Earning Those Credentials

Getting credentialed (i.e., enrolling in an insurance company’s preferred provider network) requires more than merely filling out paperwork. It’s actually a fairly involved process. And it’s an important one, too: credentialing helps insurance companies and government entities like Medicare determine whether you’re qualified to serve on their panels as an in-network provider. Why is that so important? Mainly because it could impact your ability to continually attract patients to your clinic. The majority of prospective patients base their care provider decisions on the answers to a few simple questions:

• Are you good?
• Can I trust you?
• Do you take my insurance?

Credentialing can also afford therapists leverage and protection if they end up leaving a specific company—that is, of course, if they’ve earned credentials as sole practitioners and aren’t working under a group contract. Now, there are plenty of things to consider when it comes to the credentialing process, but here are some initial steps you can take to get the ball rolling, as adapted from this resource:

• Secure your own tax ID number.
• Obtain malpractice insurance.
• Get an NPI number.
• Have a license to provide services in your state.
• Find a clinic location in which to practice.

Some payers also require you to submit annual updates and reapply after a certain time period to further prove your legitimacy as a provider. In other words, credentialing doesn’t always stop after you’ve submitted the initial forms.

Jumping Through Other Hoops

When a new therapist joins your practice, you’ll need to investigate his or her credentialing status with your insurance carriers. Now, even if you or your other therapists aren’t credentialed with a specific insurance company, you still have the option of billing as out-of-network providers. This could prove risky, though, as there’s no guarantee the insurance company will accept or pay those claims in full. Furthermore, if you’re not credentialed with Medicare, you cannot treat—or collect payment from—Medicare patients for any Medicare-covered services. Still, that doesn’t mean your clinic can’t see Medicare patients at all (check out this blog post to learn about your options for treating Medicare patients without being credentialed).

Today’s insurance companies may seem more limited and selective compared to years past, and that’s partially because, thanks to reform legislation like the Affordable Care Act, more patients are insured and, thus, able to access covered care. Furthermore, there are fewer insurance restrictions on patients with pre-existing conditions. Thus, to contain costs—and possibly to prevent overuse of benefits—payers are limiting the number of in-network providers available to their beneficiaries.

Contending with “Closed” Insurance Panels

Credentialing is not only time-consuming, but also—in the eyes of PTs, OTs, and SLPs—seemingly arbitrary and full of uncertainties. It generally takes three to four months to hear back from insurance panels once you’ve submitted documentation to verify your experience, expertise, interest, and willingness to provide therapy services. Then there’s the very real possibility that certain insurance companies will deny you based on selectivity or because the panels are “closed” (i.e., they’re not accepting any new providers). Knowing how to position your experience can go a long way when it comes to getting into “closed” panels—but that’s easier said than done. So, what are some of your best options for overcoming these barriers? Beyond applying to specific insurance companies every six months, you should sign up for the CAQH ProView™, a universal provider database that makes credentialing a little easier to manage—and stomach.

As the saying goes, “Nobody said that it’d be easy; they just promised it’d be worth it.” This adage definitely applies to insurance credentialing. After all, you can’t expect to attract many patients if your admitting privileges aren’t up to snuff. That’s why it’s vital that you make credentialing a priority. While it can be fraught with frustration and uncertainty, the eventual payoff means more money in your pocket—and greater business success.