Working with payers as an in-network PT almost always involves some hoop-jumping—whether it’s keeping up with the latest billing changes or negotiating a fair fee schedule. That goes double for the PTs who are only beginning to build their relationship with payers; it takes considerable effort just to get in the door. I’m talking, of course, about the credentialing process.
Credentialing is incredibly important, as it’s the process in which payers evaluate providers’ education, training, and professional history before contracting with them and offering them an in-network status. That doesn’t mean the physical therapy credentialing process can’t be frustrating, however (and oftentimes is). To that end, we’ve compiled some credentialing tips with the help of Jason Tocci, VP of Business Development at Rehab Medical Billing Services, that will help you navigate this process.
1. Know when you might need to obtain new credentialing.
This tip may feel like a gimme, but you’d be surprised how many people don’t know when they need to get new credentials—or update their current ones. Typically, providers need to enter the credentialing process:
- When they open a practice, or
- When they begin employment at a new practice.
It doesn’t matter if the provider was previously contracted with a payer; in both of these scenarios, the payer wants new credentials. According to Tocci, this is a common point of confusion. “PTs say ‘I’m already a participating provider in Blue Cross Blue Shield—won’t this be quick?’ The answer is ‘no.’ Every time you start a new job, you have to begin the entire credentialing process again with the new employer.”
Luckily, the re-credentialing process is less intensive than the initial hooplah of credentialing. Essentially, every one to three years (depending on the payer), carriers reach out to providers to confirm that the information they have on file is still accurate. “Re-credentialing is a little bit easier,” said Tocci. “It’s just filling out some information and providing that updated information to the payer.”
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2. Collect your paperwork beforehand.
Part of why the insurance credentialing process is long and tedious is because it’s incredibly thorough. Insurance carriers want to know everything they possibly could know about the professional lives of their potential providers. Roughly translated, that means you’ll need to collect paperwork. A lot of paperwork.
- Up-to-date curriculum vitae (CV)
- NPI number (Type 1 or Type 2)
- Proof of malpractice insurance
- State license
- PT diploma
- Training certificates (e.g., upon the completion of an internship, residency, fellowship)
And that list doesn’t even begin to speak to the documentation you need about your practice itself. Per Tocci, payers will also ask for the following information:
- Tax ID/ Employer Identification Number (EIN)
- Business checking account
- Proof of physical location (e.g., a signed lease or mortgage)
- Clinic phone number
- Proof of professional liability
Some payers require applicants to have a profile through CAQH ProView®: a free nonprofit national credentialing database. It may behoove you to create a profile before sending out any paperwork. For instructions on how to do this, visit this CAQH FAQ.
3. Submit your credentialing applications at the right time.
I’m gonna get a little nerdy on you, here. One of my favorite quotes is from Lord of the Rings, when Gandalf the Grey says, “A wizard is never late, nor is he early. He arrives precisely when he means to.” It’s a quirky (and I think funny) way to say, “I’ll get there when I get there.”
Unfortunately, that laissez-faire attitude toward time doesn’t really work during the credentialing process. Providers need to time their applications appropriately to begin treating patients when they would like to. What does that mean exactly? Per Tocci, in this mid- to post-pandemic world, “providers should expect the credentialing process with commercial payer and workers’ comp to take four to six months.” You can start those commercial payer applications as soon as you want, said Tocci, with the exception of Medicare.
You cannot begin the Medicare credentialing process until you open your doors and begin treating patients. That’s because the Medicare credentialing process requires a site inspection to combat fraud—though it’s informal, at best. “Usually, you won’t even know Medicare came in because they stick their head in the door, take a picture, and leave,” said Tocci.
The one consolation to the Medicare credentialing process, though, is that it’s much faster than it was prior to the pandemic. Nowadays, Medicare credentialing gets turned around in 90 days—if not sooner.
In the same vein, be sure to give yourself enough time to fill out each credentialing application. The processing time is long enough—but this company reports spending 10 to 12 hours simply filling out each application. It’s a decent chunk of time, but it’s important not to skimp on the process.
4. Pick your closed panel battles wisely.
Before sending out your credentialing applications, conduct some research to determine if your ideal payers have open or closed panels. If the payer has an open panel, it’s credentialing new providers. If the panel is closed, it’s not accepting new providers at this time.
For the most part, Tocci recommended not bothering with closed panels—especially if you’re paying for a credentialing service. “If it’s closed, it’s closed,” he said. “It’s best to put your eggs in another basket.” There are very few reasons that a closed panel may accept a new provider—but it’s usually not worth pursuing. Instead, he suggested prioritizing your business expenses and spending your money on getting into open panels.
Instead, Tocci suggested pivoting to market to patients with other regional insurances, and to look into offering out-of-network services.
That said, Tocci had slightly different advice for those who are spearheading their own credentialing. “If you’re doing this on your own, apply to everything,” he said, “If it’s an important payer, you should still reach out and get the official denial from them, because some payers maintain your information. When they have a need in their area, they’ll reach out to you.”
Navigating the credentialing process may be a little difficult at times, but all healthcare providers have to muscle through during their careers. The best advice we can leave you with is to be prepared! So pull up your favorite search engine, and get crackin’!