When a new clinic is getting started or whenever an existing one is looking to expand its client base, one crucial—albeit complicated—piece of the business pie is credentialing. Without a clear understanding of what it is and how to go about completing the process, several pitfalls await the unwary applicant. So with that, we here at Rehab Medical Billing Services (RMBS) have partnered with WebPT to give a clear and concise FAQ for all things credentialing.
What is credentialing and why is it important?
Credentialing is the process in which payers verify that a provider—or company—is qualified to participate in their network and provide treatment to their patients. This is an extremely important process if you are wanting to treat patients in-network. Without credentials, you are a non-par (non-participating), OON (out-of-network) provider.
Is the credentialing process different in an inpatient setting vs. an outpatient setting?
Yes, the process for an inpatient setting tends to be easier and quicker as most payers do not require the individual clinician to undergo the credentialing process.
What is an NPI?
NPI stands for National Provider Identifier. It is a unique identification number assigned to individuals and organizations. All HIPAA-covered healthcare providers are required to get an NPI.
What is the difference between a group NPI and an individual NPI?
An individual NPI (Type 1 NPI) is assigned to individual clinicians while a group NPI (Type 2 NPI) is assigned to organizations. It is often called a group NPI or billing NPI.
A sampling of individuals that are required to get an NPI include:
- Physical Therapists,
- Occupational Therapists,
- Speech Language Pathologists,
- Physicians
- Audiologists
- Psychologists
- Dentists
- Nurses
- Pharmacists
- and Chiropractors
Examples of organizations that require a group NPI include:
- Outpatient clinics
- Group Practices
- Health Maintenance Organizations (HMOs)
- Home Health Agencies
- Hospitals
- Laboratories
- Residential treatment centers
- Durable Medical Equipment (DME) suppliers
How do I establish a group NPI?
You must apply for one through the National Plan and Provider Enumeration System (NPPES) website, which takes roughly 15 minutes. All in all, it can take up to 30 days to obtain an NPI—Type 1 or Type 2. However, obtaining the NPI via an email response typically takes just a few hours.
How can I link individual providers to a group contract?
This process is different for each payer/insurance company. Some require an email, some a fax, and others utilize online portals. However, most require an application to be completed and additional documents to be provided.
If I’m part of a practice or facility that has a group NPI, do I also need an individual NPI?
Yes, an individual NPI is required for all providers working within outpatient clinics/facilities. Inpatient facilities bill differently, and you may not need your own NPI, so I would recommend consulting with your director to determine its necessity.
Can I be credentialed at multiple places with multiple employers?
Yes you can. The only potential issue is if one of your employers is out of network with a certain payer and another employer is in network with that payer. This may cause billing issues for both employers.
If I’m not yet credentialed (but currently in the process), can I begin treating patients?
You can treat patients, but you are technically out of network. Therefore, you can charge the patient cash, or bill their out-of-network benefits if they have them. Medicare allows you to treat patients (and hold claims) while your application is being processed. Once you are approved, you can provide your approval letter to your billing staff, and they can release your claims to be processed and paid.
In clinics with more than one treating rehab therapist of the same discipline, the credentialed therapist can co-sign the documentation of the uncredentialed provider to ensure that there are no delays for in-network billing. This is common for private insurers but should be verified before proceeding.
What would I need to renew my credentials, and how would I start that process?
It depends on the payer, but I know WebPT has an article that walks clinicians through the scenarios in which they may need to renew their NPI—it’s definitely worth a look. Regardless, as long as you maintain your profile with the Council for Affordable Quality Healthcare (CAQH) database, re-credentialing is relatively easy.
Do therapy assistants need to be credentialed?
No, PTAs and COTAs do not get credentialed.
Do my credentialing requirements change if I choose to become a travel therapist?
The clinic where you will be assigned will need to process your credentialing under their group contracts. This process is often handled between the travel company and the assigned clinic. Maintaining a record of work and education experience, continuing education, and certifications/specializations can streamline the process from travel contract to travel contract.
How long does the credentialing process take?
The process—and timeline—varies by payer. However, commercial payers, Medicaid, and worker’s compensation take an average of four to six months. Credentialing through Medicare is surprisingly a little faster and takes roughly 30-60 days. Once you are credentialed, there may be more steps to follow, so be sure to stay on top of any of these hurdles as they come.
How does credentialing impact my business?
Credentialing should have a positive impact on your business. Credentialing will allow your business to appear as an in-network provider in the payer directories. As an in-network provider, patients can find you when searching for a rehab provider and then be treated at your clinic knowing what their financial obligations are.
How do I ensure I get the best rates possible from the insurance company?
Upon the initial credentialing stage, it is often recommended you accept the contract and reimbursement offered. Most payers will not negotiate reimbursement rates and attempting to do so can lengthen your credentialing process from four to six months to well over a year. We recommend that you revisit your reimbursement rates once you have been participating with a payer for several months to over a year.
Be sure not to wait too long before revisiting the rates though. As this article describes, experts believe that providers who consistently ask for small rate adjustments each year achieve better results than those who sporadically ask for bigger bumps. Leveraging patient data related to outcomes—easily achieved through WebPT’s Outcomes and Keet Health—and building provider-payer rapport can yield the reimbursement rates best for your clinic.
Do I need to notify my payers of any changes in my clinic information?
Yes, any changes in your physical address, mailing address, ownership, or any other significant changes need to be reported to your payers. Medicare requires you to report changes within 30 days.
Are there companies that can help manage the credentialing process for me?
There are companies that will perform credentialing for your company and clinicians. At Rehab Medical Billing Services (RMBS), we manage the entire credentialing process from adding a new therapist—or location—to your existing clinic to starting up your brand-new clinic with the initial credentialing and contracting process. In addition, through membership at WebPT, the WebPT marketplace also provides credentialing services and assistance.
Credentialing can be a scary prospect and process for any seasoned or green clinic owner, but there are many tools available to lighten the load and assist in streamlining the ordeal. One such useful tool is WebPT’s free billing guide that covers all things billing from credentialing, to payer contracts, to CMS rules, and much more. If you have any other questions, feel free to comment below and the experts at WebPT and RMBS can help you out.
