Starting a new therapy practice can be daunting as healthcare providers have to go through complex protocols to be called legitimate and reimbursed by the insurance companies. Before contracting with insurance payers for medical services, payers undergo credentialing of therapists to check the status of their legitimacy and competency. Insurance credentialing for physical therapists is done by payers as per rules and regulations set by the American Medical Association (AMA).
Medical credentialing ensures that the provider has the appropriate skills and expertise to render medical services to the patient. The steps involved in the credentialing process are intricate and crucial, and every provider should get information before applying for credentialing. In this guide, we will learn the steps involved and the importance of the credentialing process. We will also discuss the documents needed and various credentialing challenges.
What is Insurance Credentialing for Physical Therapists?
Insurance credentialing is the verification process in which credentials like educational degrees, licenses, training certificates, and work experience are evaluated to determine whether a specific provider can provide standard care to insured patients or not. Insurance credentialing also allows providers to get their claims accepted and reimbursed for the rendered medical services.
For physical therapists, additional credentials, including physical therapy training certificates, are verified to ensure patient safety and protection. Credentialing is essential as most patients like to get treatment from in-network providers. Therefore, credentialed providers have access to a large pool of patients. Enhanced patient volume plays a major role in stable income and financial growth. Credentialing also develops a sense of safety among patients, acting as a bridge between patients and doctors. This signifies professionalism and credibility.
Steps for Insurance Credentialing
We are just mentioning the useful steps for Credentialing Process in this blog, because there already a well-written and informative blog as well as visual flow chart for credentialing process so you can check them out to have a perfect idea. Otherwise, continue reading:
1. Gather Required Documents
The credentialing process requires extensive documents that are used to assess the educational status and skills of the provider. It is wise to go through general credentialing guidelines and gather all necessary documents beforehand. If you start the credentialing process and some of your documents are missing, then it wastes time, and even your application can be rejected. The following are important documents that should be gathered:
- Curriculum Vitae (CV)
- NPI Number
- Proof of Malpractice Insurance
- Training Certificates
- State Licence
- PT Diploma
- Tax ID/ Employer Identification Number (EIN)
- Business Checking Account
- Proof of Physical Location
- Clinic Contact Information
- Proof of Professional Liability
2. Obtain NPI Number
A National Provider Identification (NPI) number is important for credentialing as well as billing purposes for PTs. Each provider gets a unique NPI number, and providers are identified by NPI numbers in health records. Insurance companies also send reimbursement for medical services to providers using their NPI number. Therefore, it holds significance in insurance credentialing for physical therapists. NPI numbers can be obtained from the NPPES (National Plan and Provider Enumeration System) website. Provider can fill out the online application available on the website.
3. Choose A Suitable Insurance Company
It is recommended to choose an insurance company with which you want to contract to provide health services to injured patients and get reimbursed in return. There are certain factors that should be assessed for choosing an insurance payer. Check whether payer open or closed panels because only open panels accept new providers. Submitting applications to closed panels only wastes time and resources.
Geographical location and reimbursement rates are other important factors. Always choose a payer that is local dealing with your community. Providers can choose Medicare and Medicaid as well, as these payers offer large patient volumes and good rates. Go for a payer who offers competitive rates for physical therapy sessions and services.
4. Submit Credentialing Application
After gathering all necessary documents and selecting suitable payers, filling out and submitting applications is the next milestone. Providers can fill and submit applications manually to the insurance payer’s office. Some payers use third party services like CAQH ProView and get the necessary information from the provider profile. This method is more accurate and reliable. CAQH profile provides updated information about the provider, which is used for verification.
5. Follow-Up & Contracting
Insurance credentialing is an extensive process; therefore, it is necessary to track application status. In case of any objection or missing information, address the problem as soon as possible to avoid delays. Provide additional information and documents if needed. Follow-up helps to avoid hiccups in the process and get the final report quickly.
After approval of the application, the provider can sign an agreement with the insurance company and get reimbursed. Negotiate reimbursement rates with the payer to align your financial goals.
Challenges in Credentialing for Physical Therapists
Physical therapists face a few challenges while applying and following the credentialing process. Providers must pay heed to these challenges and find the best solutions to overcome them. As we know, it is a complex and time-consuming process; providers need to wait for final approval, and they can’t treat patients in waiting periods. This leads to financial loss. So, there is an already well-written blog for the credentialing cost with insurance companies, so check this one out.
Insurance credentialing needs numerous documents, from educational certificates, training proofs, and licenses to work experience proof. If the provider fails to submit even one document from above, then the application is rejected. This is a challenge for providers and to overcome this, they need to track the whole process and rectify the error at once. Providers can also seek help from medical insurance credentialing services, by outsourcing their insurance and billing processing. These services help you to submit, track, and get approved for your credentialing application.
It is not a one-time step, as payers require periodic revalidation of providers’ documents. This adds an administrative burden to the physical therapy practice. If we talk about reimbursement rates, then we see that small practices face problems negotiating rates and end up agreeing on lower reimbursement rates than the standard. This unjust behavior hinders the financial growth of physical therapy practice.
What is a CAQH profile?
Council for Accountable Quality Healthcare (CAQH) is a free platform that is made to facilitate administrative processes and work. CAQH ProView is a web where healthcare professionals can make their profiles have personal and professional information. This CAQH profile is updated periodically by providers to keep information fresh.
CAQH profile can only be accessed by authorized members. This keeps data secure and private. When credentialing with payers, healthcare providers give authorization to payers to use the information. The struggle to fill out a new application each time a provider applies for credentialing can be avoided by using a CAQH profile. It also reduces paperwork and human errors in filling out application forms. We have also covered some blogs like attestation and maintenance, relation of CAQH and Credentialing and everything about CAQH so do check them out!
Conclusion
Insurance credentialing refers to the verification process in which educational degrees, licenses, training certificates, and work experience letters are evaluated. This process helps to check the legitimacy of documents. On approval, providers have the right to submit claims and get reimbursed for rendered healthcare. Credentialing steps should be followed to undergo the process effectively. Providers need to choose the payer and gather all necessary documents as per requirements set by the specific payer.
An NPI number should be obtained, and an online application can be submitted. Authorization to access the CAQH profile helps payers to seek all kinds of information for verification. On approval, sign the contract and you are good to go now. Large waiting periods, revalidation, and complex requirements are potential challenges in the credentialing process.
FAQ - People Also Asks
Insurance credentialing is a process in which healthcare providers are verified whether they have skills and expertise for healthcare or not. Credentials of providers like physical therapists are evaluated by insurance companies before contracting and reimbursing them.
Yes, it is time taken proces and Medical credentialing can be considered hard due to lengthy approval time, extensive documentation requirements, and intricate payers’ protocols. However, following guidelines and using credentialing services or software can make it easy.
It is a payer-dependent requirement. Physical therapist assistants (PTAs) generally do not require a CAQH profile until there is any specific requirement by the payer.
In therapy, credentialing means verifying the certificates, degrees, and licenses of therapists to ensure that they are professional enough to render medical services to the patients. Credentialing allows therapists to receive in-network patients and reimburse payers for healthcare services.