Before startup clinics can open their doors, they have to check a lot of boxes. They must find a location, furnish that space with equipment, create a patient base, credential new providers, fill out tax forms—you get the idea. Opening a new clinic is tough work, and it’s only made tougher when insurance companies throw up unexpected barriers—like closed panels. Sometimes, when payers have contracted with too many providers in a specific area, they’ll deny new credentialing applications, stating that their panel is closed.
But, even though this particular barrier can create a headache of epic proportions, providers shouldn’t pack it in the minute they see that a panel is closed. A payer with a closed panel may still accept providers—if only on a case-by-case (and limited) basis. In other words, all hope is not lost, because the provider may be able to convince the payer to make an exception. Plus, there are other methods providers can use to navigate tricky payer panel situations. Read on to learn more!
1. Determine whether your local panels are closed before you submit your credentialing application.
In a perfect world, providers would always have time to craft and submit the best possible credentialing applications. Unfortunately, that is rarely the reality. I mean, this site recommends devoting ten hours to each credentialing application. (Wowza!) Still, if you want to be accepted into a closed panel, then devoting a decent chunk of time to your credentialing process is a must. Your application’s gotta shine like the North Star!
If possible, scout out your payers before you even begin the credentialing process. For any whose panels are closed, put some extra oomph into your application from the get-go.
Cleaning Up Your Application
As you work on your application, remember that your goal is to present yourself as an ideal provider who can offer things that other providers do not. For instance, Tamara Suttle recommends showcasing your:
- Cost efficiency,
- Excellent outcomes,
- Ability to serve underserved populations (if applicable),
- Ability to speak multiple languages (if applicable),
- Unusual clinic hours (if applicable),
- Experience treating niche populations, and/or
- Additional training and credentials.
Think of the application process like you’re filling out a resume. This is not the time for modesty!
Sussing Out Closed Panels
Unfortunately, determining upfront whether a panel is closed isn’t always the easiest task in the world. (Go figure!) In some cases, you may need to:
- Consult with a credentialing company;
- Reach out to friendly (local) industry peers who contract with the payer or who’ve recently gone through the credentialing process; or
- Contact the managed care team at a local hospital.
2. Write a letter of appeal.
If your payer of choice denies your credentialing application, then you must write a letter of appeal (usually to the provider representative) to keep the process moving forward. This letter is your chance to make your case to the payer and prove your potential worth as a preferred provider. You’ll want to include a lot of the information I touched on in section one. Talk about your cost efficiency, your efficacy, and anything else that differentiates you from other providers. These sources recommend discussing things like your:
- Access to special equipment,
- Relationship with other referring providers who are also in-network, and
- Affiliation with other in-network providers (payers apparently like working with groups).
3. Contact the right people.
If waiting to hear about the results of your appeal letter doesn’t sound all that appealing to you, then you may be able to speed up the process—and still successfully reverse your application denial—simply by talking to the right people. According to the sources cited here, most payers employ a network development manager and a medical director. The network development manager can bring new providers into the fold at any time. The medical director does not share this power, but may be able to influence the application process.
Asking Patients to Pitch In
Don’t forget the power of the patient! Even if a payer is inundated with requests, applications, and appeals from providers, patients can help cut through the noise. If you plan to see any patients who are insured under a payer that you’re struggling to get contracted with, ask those patients to contact the company and request or nominate you as a provider.
4. Ask for a single-case agreement.
Instead of writing a letter of appeal or relying on patients to help swing the pendulum in your favor, you could ask the payer for a single-case agreement—that is, a contract between you and the payer through which you essentially become “in-network” for one specific patient. The idea behind securing an agreement like this is that it allows you to show the payer firsthand how valuable you are—and what an asset you would be to the payer’s panel. Furthermore, it’s cheaper for the payer to transition you from a single-case agreement to a preferred provider contract than it is to start a fresh credentialing process with a new applicant.
Securing a Single-Case Agreement
Unfortunately, securing a single-case agreement isn’t the easiest feat to pull off. According to this billing site, your patient’s situation should meet one of the following conditions:
- The patient requires treatment from a clinical specialty that is not already available in-network;
- The patient cannot locally access the appropriate in-network care;
- Your treatment will keep the patient out of the hospital; or
- The patient recently switched insurance carriers.
At the risk of sounding like a broken record, you essentially have to prove to the payer that your skilled care—and your skilled care alone—offers benefits to both the patient and the payer that they simply cannot ignore.
5. Keep applying.
If you receive an application denial, don’t give up hope. Keep applying! Insurance panels won’t stay closed forever—in fact, payers typically reevaluate their panel every three months (though this varies from payer to payer). Even if you couldn’t make a splash with your application this time around, it’s worth trying again.
6. Start treating patients out-of-network.
If the payer continues to deny your applications and appeals, it’s probably time to activate a plan B (at least until you get plan A sorted out). In this case, I recommend looking into out-of-network billing. Some providers find a lot of success billing out-of-network or creating cash-pay programs in their clinics. This could be the perfect time to branch out of the insurance sphere. How’s that for a silver lining?
Closed insurance panels may feel like a huge pain in the neck, but as far as challenges go, they’re not insurmountable. If you play it smart, you should be able to navigate over or around them, and continue to find success in your clinic.