ADVERTISEMENT
Successfully Navigating The Insurance Credentialing Process: What Podiatrists Should Know
This content was created in partnership with the American Podiatric Medical Association.
Whether entering practice after residency, opening a new practice mid-career, or changing practice settings, insurance credentialing can prove to be a complicated and arduous process. Here the author shares her experience and knowledge to help podiatrists learn more about succeeding in this challenging pursuit.
In the ever-changing world of health insurance companies, insurance panel credentialing of new providers remains fairly constant. In order to obtain a coveted participating provider contract, providers must go through an extensive and lengthy process to demonstrate and verify their education, training, and prior work experience. However, the greatest difficulty is actually getting to the point where one can begin the credentialing process. This challenge stems from frequent closure of insurance provider panels due to oversaturation of other providers close to your practice. This article will lay out a step-wise process that may help you overcome some of the obstacles to getting on these different insurance panels.
Where Do I Even Start?
First and foremost, you need a license to practice podiatry in your intended state.1 This process can take many months, so it is a good idea to start as early as possible. Different states have different requirements, and some require the passage of state-specific examinations only offered at certain times of the year. You can check the State Board of Podiatry for the state you are interested in to see the exact requirements. Furthermore, keep in mind that the podiatric scope of practice is also state-dependent, and you need to be sure you are comfortable with what this could limit for you as a practitioner. Once you have received your license, you need to ensure that your National Provider Identifier (NPI) number is up-to-date with the proper taxonomy and demographic information. You will also need to be sure that you have your malpractice insurance, Drug Enforcement Agency (DEA) number, physical practice location, and all certificates of training or radiology needed for your state. It is essential that you update your curriculum vitae (CV) as well, as this is often a requirement in the first steps of the credentialing process. Be sure to account for any gaps in your education, training, and career.1,2
Once you have decided on which insurance panels to apply for, you will need to make a very calculated decision and choose between getting a solo versus a group practice contract. If you decide to go with the latter, you will also need to reach out to your state governing board and, at times, an accountant or lawyer, to find out the best business structure for your practice. After gathering all this information, the next step is applying for and obtaining a Council for Affordable Quality Healthcare (CAQH) number, thru the Council for Affordable Quality Healthcare, which many companies use throughout the credentialing process.3
Once you finalize the above items, you are finally at the stage where you can contact the different insurance companies and start inquiring about their panel requirements. One should keep in mind that while some company provider relations liaisons are open, friendly, and easy to get ahold of, others leave much to be desired, and their representative may not respond to you at all. Do not be afraid of going to the insurance company headquarters if they are easily accessible. You may get a lot more information in person and can build better relationships that will help you on your journey. However, if you are lucky enough to interact with someone in the former category, you may still find that their panel is closed to all new providers. You may feel defeated, but there are many different and creative ways to navigate the system and still potentially find your way onto these closed panels.
What Options Exist if Panels are Closed?
The simplest way to go about this is to check the list of providers on the insurance panel to see if any of them are no longer in practice. Another option is to look through the list of providers to see if anything stands out about your training or expertise in relation to the other providers on the panel. If your training far exceeds the others on the panel, do not be afraid to let yourself shine. If you can find a provider who is no longer practicing or can provide a much-needed service, contact the provider relations liaison and let them know to see if this opens any doors to credentialing. An appeal letter outlining your individualized points is a great way to get your foot in the door and have them understand what you really have to offer.4 You can also check to see if there are any providers on the panel with whom you have a friendly relationship. If you have a great referral source, this individual can be an in-network partner for you, and if they are willing to contact the provider relations department on your behalf or write you a letter of support, it will make you a stronger candidate.
If none of the above works, your best bet will be to contact the provider relations department regularly to see if anything opens up. Most companies have at least quarterly meetings where providers are brought on and taken off their panel, and the sooner you get this information, the faster you can find yourself replacing that person. If you still find no progress, you can try talking to the different panel providers and see if any of them are looking to retire or leave the area. This is a great way to get onto the panel because the person you could replace will be the one to reach out to the company and let them know that they should take you on. It is also a great time to let your credentials speak for themselves, especially if you have something that stands out compared to this current panel provider.
Navigating the Final Stretch
Once you receive the green light to proceed with the credentialing application, you need to closely monitor everything to avoid any delays in processing. All communications should be in writing and time-stamped to prevent possible errors. Do not be afraid to reach out regularly for updates on your file. The entire process is lengthy and time-consuming, taking up to six months to a year at times.2 It is crucial to allow yourself enough time to get credentialed if choosing to go down this route on your own. Make sure that you track all sent mail and require a signature, in case the documents become lost. Again, make sure always to have backup copies of everything submitted if something cannot be found. It is not uncommon to learn that your application is completely lost, and you have to start the process all over again.
When you finally achieve your insurance credentials make sure to read your contract closely to be sure the terms are exactly what you planned to sign up for and nothing less, because in the end, these companies are in it to make a profit, even at your loss.5If you do not want to take on this lengthy and arduous task on your own, various companies will do it for you. It is essential to understand that, at times, these individuals have many years of ongoing relationships with those in the provider relations and credentialing departments and could provide you better access and possibly a jump start on getting onto the panel. Whatever you do, do not give up; this process can be time-consuming and requires great patience.
Dr. Karamloo is a Diplomate of the American Board of Podiatric Medicine and a Fellow of the American College of Foot and Ankle Surgeons. She practices in Morgan Hill, CA.
1. Getting on insurance panels: how to navigate the process. Therapynotes. Available at: https:blog.therapynotes.comgetting-on-insurance-panels-how-to-navigate-the-process. Published May 22, 2018. Accessed May 20, 2022.
2. Insurance panels: what they are and how to get on one. Theranest.com. Available at: https:theranest.combloginsurance-panels-what-they-are-and-how-to-get-on-one . Published May 19, 2017. Accessed May 20, 2022.
3. CAQH Proview. CAQH website. Available at: https:proview.caqh.orgLoginIndex?ReturnUrl=%2f . Accessed May 20, 2022.
4. Maher T. Insurers’ closed panels: should providers accept or appeal? LinkedIn. Available at: https:www.linkedin.compulseinsurers-closed-panels-should-providers-accept-appeal-tom-maher . Published May 10, 2018. Accessed May 20, 2022.
5. Brewer Jr. LG. Insurance credentialing: maybe so … Practiceoftherapy.com. Available at: https:practiceoftherapy.cominsurance-credentialing-maybe . Accessed May 20, 2022.
