Credentialing Blues

August 20, 2015

After 35 years in the business of medical practice administration, I still do not understand why clinicians have so much difficulty understanding insurance carrier credentialing.

Everyone in the world knows that the money from a medical service insurance claim comes from an insurance company.

How does the insurance company know who to pay, you might ask? A logical question. The claim form sent to the insurance company has a “pay to” section where the provider’s information is listed, along with tax ID numbers, NPI numbers etc., identifying the provider seeking this payment.

Another question might be, how does the insurance company know this is a “real” clinician and not someone fraudulently seeking money from them?

The $64,000.00 question! The answer is provider credentialing. This is a long, arduous, complicated process where the clinician must “ask the carrier to admit them to their roster.” I emphasize the “long” here as I can name some companies that take 6 months to process applications. The average time is 90-120 days if the application is followed diligently. Once an application or letter of intent is received and processed by the carrier, the journey starts. The carrier has various stages; i.e. receipt, input, review, contracts, finally an approval and then a welcome letter.

While all of this is happening (or not), the provider cannot treat anyone with this insurance.

So you may be saying, ok, once it is done, I won’t have to deal with it again.

Oh no, no. CMS and State Medicaid programs require completing the process every 2-5 years. If not compliant with requests that are not sent “certified mail” and could be going anywhere but to the right address, they cut your payments unceremoniously.

If you have moved, changed your practice status, joined or left a group, this all has to happen again before you can be paid.

This is just a thumbnail sketch of the nuances. As the person who usually gets the panic call about claim denials, I ask that you anticipate your moves and plan for the changes required to keep payments coming. It is never too early to advise the staff or consultant responsible for credentialing when changes will occur.
Remember, carriers will not pay claims for services rendered prior to the “welcome letter.”

Help us help you – anticipate, communicate.

For more information on NEARM’s Credentialing services, call us at (800) 464-7885 x. 1514, email us at, or print out this email, write your name, practice and contact information on it and fax it to (781) 231-7673.