Today’s episode is all about credentialing with insurance panels.
So, today is the first in a three-part mini-series, rather on insurance in the testing practice. Today, we’ll talk about credentialing. In the next episode, we will talk about billing and getting paid through insurance. The final episode in the mini-series will be how to request raises from insurance companies. So, if these topics sound interesting to you, now is a great time to subscribe or follow the podcast if you haven’t already so that you don’t miss any of these upcoming episodes.
If you are an advanced practice owner and you would like to get some accountability and support as you take your practice to the [00:01:00] next level, I think this is the last time I will be promoting the Advanced Practice Group on the podcast because, at the time of the recording, we do have an opening in the group. At the time of the airing, chances are the group will be closed, but I’m going to give it a shot anyway. If you want to sneak in at the last minute, this might be your opportunity. So you can go to thetestingpsychologist.com/advanced, learn more about the advanced practice mastermind group and see if it will be a good fit for you.
Okay, let’s get to a discussion about insurance panel credentialing.
[00:02:00] Okay, y’all, here we are talking about insurance panel credentialing for testing psychologists. Now, when I say for testing psychologists, that’s actually not true. Insurance panel credentialing is pretty universal across the board, but there will be a couple of little layers that apply to testing folks that I think will come into play, if not today, then certainly over the course of the insurance mini-series. So let’s go ahead and just dive right into it.First of all, deciding whether you want to credential with an insurance panel or many insurance panels is a big choice. And if you’re anything like me, you don’t know exactly what that entails. So let me take just a second and talk about what that actually means to credential with an insurance panel and “take insurance.”
At its [00:03:00] core, what that means is that you are entering into a contract with an insurance panel to abide by their guidelines and regulations in order to prefer to provide clinical services or in some cases, nonclinical services that you may try to bill for. Getting a little deeper into that, that means that you contract with the insurance panel to see the members of their insurance panel, the clients to have that particular insurance, and you agree to accept that insurance that you are paneled with.
So if a client comes in, they have Blue Cross Blue Shield, you’re paneled with Blue Cross Blue Shield, that means you “take their insurance.” So, that means that you have agreed to the guidelines set forth by Blue Cross Blue Shield for seeing their patients, [00:04:00] and you will file an insurance claim on the client’s behalf to be considered for payment.
Now, that also means a part of the contract that you agree to is the reimbursement schedule and policies. When I say contract, this is a literal contract. It’s lengthy. These are lengthy legal documents that you are signing to enter into with an insurance panel. And they have all sorts of declarations and stipulations. To be honest, I don’t know anyone who actually reads through all the pieces of the insurance contract. You certainly should, but I don’t think many people do. But it is a legal document. You are bound by this document that you have signed with the insurance panel.
What are the big things that people are most curious about? Naturally, it’s [00:05:00] the something called the fee schedule or the rate schedule.
And that’s simply the agreement between yourself and the insurance panel talking about how much they will reimburse you for the services that you provide their members.
Often, the insurance reimbursement rate is lower than the out-of-pocket rate for that area. So keep that in mind. That’s not always the case. And in some cases, insurance reimbursement rates can certainly approach the out-of-pocket or market rate, but in some places, there is a vast discrepancy.
In certain parts of California, I know this is the case. And there are many other parts of the country as well. But that’s one thing to really pay attention to in your contract is, what is the fee schedule?
Now, I will talk about this more when I get to the episode on asking for raises, which is two business episodes down the road, but just a quick plug to let you know that you can [00:06:00] negotiate rates right off the bat before you sign your contract with the insurance panel. You can request higher rates. Don’t be afraid to do that if the rates look a little low.
All right, so the contract that you signed, you choose to enter into this agreement to accept their agreed-upon rates for your services. So that at its core is what it means to take insurance.
Now, in that contract, there will also be guidelines around testing services and other services. It’s not just testing that gets picked on. There are plenty of other services in the medical world that insurance panels have to consider whether they are “medically necessary” but this is something that comes up with testing a lot.
So know that if you enter into an agreement with an insurance panel, you may have to abide by their [00:07:00] guidelines for medical necessity of services, which basically means they get to decide whether the testing that you’re doing is reimbursable or not under their plan. And often the criteria is whether that testing is “medically necessary”. So just know that entering into an insurance contract will mean that the insurance panel again, gets to dictate the terms for the testing that you might do.
Often, I’d say almost always, academic testing is not considered medically necessary nor are auxiliary testing services like forensic work, substance use evaluations, independent educational evaluations, really anything that you can’t make a case for it to be medically necessary. So, anything that a client chooses to go through on their own or just for their own curiosity, that’s going to increase the likelihood that insurance will not cover it.
[00:08:00] So, just a few things to know about entering into a contract with an insurance panel. Now, this is the inverse of credentialing, but if you want to de-credential, please know that most of the time that will take you anywhere from 30 to 90 days to do that as well. So if you want to get off of an insurance panel, that’s a bit of a process also.Okay. So we’ve laid a little groundwork. Just to talk a little bit more about the finances here, generally, there are a couple of situations that are numbers or figures that you have to keep in mind when you take insurance. But at its core, I get the question a lot of, “Well, if I take insurance, does that mean that I can charge clients the balance between what the insurance pays and what my out-of-pocket rate is?” And the answer is no, you can’t do that except in very specific situations where you have the permission [00:09:00] of the insurance panel to do that.
So I’ve talked about balanced billing, which is what that’s called on the podcast before. I won’t dive into that deeply here because I’ve covered it before, but there are certain situations where you can engage in balanced billing if the insurance panel gives you permission to do so. So generally speaking, you agree to accept the insurance rate and that’s that. So clients, when they show up, we’ll either have to pay a code-pay, let’s call it a code-pay. So that’s a set somewhat lower rate that they owe for each time that they come to your office.
For example, a client might have a code-pay of $25 for each office visit. That means they would just owe you $25 for each time they come in and the insurance panel will reimburse the rest of the fee up to the agreed-upon rate. So, let’s just say that your insurance panel reimburses $100 an [00:10:00] hour, the client has a $25 code-pay, then insurance will write you a check or make a deposit for $75. So that’s a code-pay.
Now, Coinsurance is something you might run into as well. Coinsurance is when the client owes a percentage of the charges that were billed. So again, if you are billing $100 an hour and a client has a 30% coinsurance, then they will owe $30 for one hour. Now, if you’re doing testing, and let’s say you bill five hours on that office visit, the total would be $500. A client has a 30% code-pay. So that would be $150 for that visit.
The other number that you need to be aware of is the deductible. Many plans have what’s called a deductible that has to be met before the plan kicks in reimbursement. So this just means that the [00:11:00] client has to pay a certain amount out of their pocket before their benefits really kick in. So if a client has a $1000 deductible on their plan, let’s say, and they come in and they do 12 hours of testing at a $100 an hour rate, but they have a $1000 deductible, then they will have to pay the first $1000 and then the remainder typically defaults to whatever coverage they have after the deductible. So, then you might get a $25 code pay after the deductible is met, or you might get that coinsurance after the deductible is met. So, just a little bit about the ins and outs of insurance payments and charges and so forth.
Now, I am getting deep in the weeds here about the basics of insurance, but what we’re really here to talk about is credentialing with insurance panels and what you need to [00:12:00] be aware of as you go through that process. But the rationale here is that before you credential, you have to know what that even means and what you’re getting into. So, I wanted to spend a little bit of time just talking about what it even means to credential with an insurance panel and enter into that agreement.
So, let’s transition and actually talk about what this means. So how do you credential with an insurance panel?
Well, there are just a few steps and it’s actually quite straightforward, and then you wait. Here are the steps that you need to consider. The first step is that you basically just need to prepare. So to apply or try to credential with an insurance panel, you’re going to have to fill out a really, really long online application that you submit to a database called The [00:13:00] Council for Affordable Quality Healthcare, Inc. or CAQH.
Like I said, this is a very long application. I would definitely set aside at least two hours to do the application itself online. I’ll have a link to that in the show notes so you can quickly. But generally speaking, you want to be very prepared to fill out that application. They are going to ask for tons of information. You want to have your employment history, your training history, your practice location, your NPI number, your Malpractice Insurance, your license, all kinds of things.
I’m jumping ahead of myself, but I wanted to let you know that the thing you’re preparing for is you’re preparing to fill out your CAQH application.
[00:14:00] And the reason that’s important is because CAQH is again, this, this online database, and that is where the insurance panels are going to access your information during the credentialing process. So, you fill out this information once, it goes into CAQH into that database, and then as you apply for each insurance panel, they will pull your information from CAQH. That’s what we’re doing here.Okay, let’s get back to preparation. So these are just a few things that you want to make sure and have ready. So, you want to have all of your demographic information: name, address, phone number, and that means home address and office address. You want to have the location where you’ll be billing. So, your billing address or your service address. Most of the [00:15:00] time, this is your office address. So it should be fine unless you have multiple locations, then it gets a little more complicated, but you want your office address and that should be the place where you’re rendering services and where you will be billing from, and your mailing address. So all your demographic info.
You want to go back and update your CV as well. The reason you want to do this is because CAQH is going to ask for your entire training and employment history. So you want to go back, you want to get your information from your undergrad institution, your grad school, or grad schools. They ask for very detailed information like the address of your school or your department, certainly dates of graduation and degree and things like that. So you want to have a really clear [00:16:00] handle on your training information and degrees, and anything you obtained over the course of your education. So get all the information you possibly can about your educational institutions and programs.
You are also going to want to update your CV with your employment history. Let me go back. There’s actually an intermediate step there. So, CAQH we’ll also ask about any postgraduate training. A little bit of a gray area, but they will ask about your internship. They will ask about your postdoc experience as well. So make sure that you have that information. And you will notice in CAQH that it is really written and kind of geared for medical providers. So, they’ll use terms like medical school instead of grad school or residency instead of internship or postdoc or fellowship, instead of postdoc, things like that. [00:17:00] So just know that and be on the lookout.
So you’ll want to update and just make sure you have, again, at your fingertips, your training history, your internship, your post-doc, and then you want to make sure that your employment history is totally dialed in as well. This means dates, locations, any information you can gather about your employment history.
Now, you also want to prepare all of the practical documents. So, you will absolutely need your license and proof of license because you’re going to upload that to your CAQH. You will need your professional liability insurance. You will also need insurance for your premises like if you rent and you have to have [00:18:00] office insurance for falling and accidents and things like that. Let’s see, you will most likely have to upload your CV. So make sure to have that on hand.
So, gather all those practical documents as well, and make sure that you have those all in one place and ready to go. If you’re someone who is board-certified, or you have some other advanced training or credentials that you’d like to make the insurance panels aware of, you will also need the paperwork to document your board certification or any other certification or training that you’re trying to work with.
Okay, two other things that you will need if you don’t have them. You will need an NPI number. I recommend getting an NPI 1 which is an [00:19:00] individual NPI number and an NPI 2 which is a group NPI number. You may never need the group NPI number, but if you have any aspirations of hiring or growing as a group or having a group contract with an insurance company, the NPI 2 will be really handy.
I stumbled into this in the beginning and didn’t really know what I was doing, but I got an NPI 1 and NPI 2, and it has paid off in spades over the years because the bind that you might find yourself in is that you apply for an NPI 1 and get your individual NPI and then 5 or 6 years down the road you start to hire, or maybe it’s six months down the road and you start to hire, and all of a sudden you have to go back and get an NPI 2, and then change everything with your insurance panels. And it can just be a hassle. So I would say, apply for your [00:20:00] NPI, get the NPI right off the bat, an NPI 1 and an NPI 2 And you should be good to go.
You can get the NPI at the NPPES website. I will link to that in the show notes. It’s pretty straightforward. You fill out the information. A lot of the information we’ve talked about will come in handy when you are getting your NPI number as well. The NPI numbers are typically issued within 24 hours. And in my case, it’s always been within like an hour. So it’s very fast.
One thing that they’ll ask you to specify when you apply for an NPI is what’s called a taxonomy code. And this is just a long alphanumeric code that corresponds to your area of practice. So there’s one for clinical [00:21:00] psychologists, counseling psychologists, and so on and so forth. Any of them are relevant and will be fine. I mean, don’t pick social worker or anything like that, but any of the psychologist variations should be fine. Just make sure that you keep that consistent anywhere else you have to enter that taxonomy. So, CAQH will ask about your taxonomy code as well.
Okay. So, this is a big part of the process. Just make sure that you have everything prepared and in the same place so that you can access it when you go to fill out the CAQH application.
Once you have all of these things, then you go to actually fill out the application. Again, I will link to CAQH in the show notes, but you go to the website, you sign up, you create an account and you fill it all out electronically. [00:22:00] So again, this will take quite a bit of time. You definitely want to sit down and have a good chunk of time to do so. You can count on, I would say at least two hours. It sounds crazy, but it’s very lengthy. And you’ll likely find as you go through it that you may have forgotten something or misplaced something, or you have to look something up. For example, I know the CAQH asks about a TB test and whether you have a current TB test or whether you need a current TB test. Again, remembering that it’s geared toward medical professionals, so that’s a lot more relevant for them. So I had to look that up and figure out, do we have to have a TB test? The answer is no.
So there’ll be a number of questions like that, that you’re like, wow, that’s random and you may have to look that information up and figure out exactly how to do it. But the main thing to think of when you fill out your CAQH is [00:23:00] just that this is the information that’s really going to feed into each of your other places… anywhere you’re sending official information.
So, whatever you put into the CAQH, just make sure that you track that and it percolates down to certainly all the insurance panels, like, if you have a State Medicaid or Medicare organization, they’re going to want the same information. So just make sure you keep everything consistent with what you put into CAQH.
Once you fill out your CAQH application, then you get to go and actually apply with the insurance panels. That’s actually pretty easy in the grand scheme of things. So once you’ve done CAQH and so forth, then you just go onto [00:24:00] the websites of whatever insurance panels you want to credential with. And if it’s not obvious, you may have to dig and search a little bit, but there should be a button or a page or something that says “Join our network” or “Become a provider” or something like that. So just look for that text.
These days, everything is online, so it’s pretty easy. You’re just going to fill out some really basic information for each of these insurance panels, including they’re going to want your CAQH number, your NPI number, your tax ID, things like that. So make sure you have a tax ID. You can get that through the IRS website if you don’t have one. If you’re a sole proprietor, you can use your social security number, but they’ll likely ask for your tax ID as well. So, just make sure that you have all that information. You’ll fill out [00:25:00] again, pretty simple, short little applications for each insurance panel, and then they will go and access your CAQH information. That’s why it’s important to fill all that out thoroughly.
So you might get some kickback depending on how well you filled out the CAQH application. You may hear something from the insurance panels after you submit your application there and they may come back and say, this isn’t consistent or this information is missing, something like that. So you may have to go and fix that. But this is where you can… usually, they’ll give you the opportunity to play up some valuable services. So, this is where you definitely want to highlight your testing experience, if you happen to be bilingual, making sure that you tell them if you have evening [00:26:00] hours, that can be very attractive to insurance panels.
You definitely want to highlight any way you can any specialties that you have because, as we’ll talk about in just a minute, insurance panels are not bound to accept your application. In many parts of the country, for many specialties, insurance panels are full and you might get a rejection letter and say that they are full right now. So you have to make a bit of a case for why you should be included in that insurance panel. So, testing is certainly a specialty and I would highlight that as much as possible. And if they allow you to submit supplementary materials, I would certainly do that as well where you explain that testing is in high demand and you are one of the only practitioners who may take their insurance and make sure that the insurance panel knows that you have a [00:27:00] specialty that is not very widely available in your area.
So you go through that process with each insurance panel that you want to credential with. You do have to credential separately with each one. So just know that. And then you wait. So for some, you may hear back right away or relatively quickly within a day or two or a week. And they’ll say, we got your application and we have moved it onto credentialing, some may ask for more information, some may reject and the timeline for each of these is variable. You may not hear anything. And then all of a sudden, two months down the road, you get something back that says that you’ve moved to credentialing.
So don’t despair if that happens. What you can do is check back in with those panels and a great place to do that is [00:28:00] with a provider representative for your area. If you cannot find your provider rep, you can always call the insurance panel and work your way through the phone tree. They all usually have an option for credentialing or network services, things like that. And you can just ask who your provider rep is for your area and if that person is a great person to follow up with if you have questions about your application.
Now, I’m sure you’ve all heard horror stories about insurance paneling taking forever. I wish that I had better news about that, but it can take forever. It can be quick, but it can also take forever. So, I would not worry if it takes 2, 3, or even 4 months sometimes or longer depending on the panel. Like I said, don’t despair, but also don’t be complacent. [00:29:00] I would set a reminder to check back in with them every two weeks again with that provider rep and just say like, how’s it coming along? Do you need anything from me? Just checking in. Don’t be annoying but be persistent because it can take a while and paperwork gets lost and that sort of thing. So don’t despair if it takes quite a while, but also be diligent in following up and trying to move it through as fast as you can.
After that, then you should get a contract. These days they’re all coming through DocuSign or some other electronic means of signing a contract.
And that’s where you will get to review the contract, review the fee schedule, perhaps ask for a raise or negotiate those fees, again, based on your specialty. And once you have that [00:30:00] signed contract, make sure that you take a look, actually before you sign it and make sure that you take a look and see what the “effective date of the contract” will be. That is the date that you can actually start billing for that insurance plan.
Now, some insurance panels, not to complicate things, but some will allow you to backdate your claims or bill for claims prior to your effective date as long as you’re in the credentialing process. I would absolutely get that in writing and documented though before you count on them. So for the most part, you want to look at that effective date and that will tell you when you can move completely forward with confidence to bill and get reimbursed and be considered in-network for that insurance panel.
All right. Now, what happens if you get the [00:31:00] rejection letter back that says that they are full and don’t want any more providers? Well, you can appeal that. So you can write a letter and send it to the provider representative. And in that letter, you just want to detail exactly why you would be a good fit for this panel. So you can include things like, there aren’t many providers in your area for this panel with your specialty. There aren’t many providers with the specialty period. There aren’t many providers who take insurance for this specialty. If you want to get really detailed, you can provide information about the population of your area and how many credentialed providers there are to serve each individual in your area.
I had to do this with Optum several years [00:32:00] ago when I was negotiating for a raise actually, but I broke it down and found how many children are in our school district from the ages of 5 to 18 and how many Optum providers are in the area and how many Optum providers specialize in testing. I did the math and found that basically equated to 1 Optum provider for every, it was something ludicrous, it was like 1 for every 9,000 children in our district or something like that.
And so you can break it down in that much detail if you’d like, and you can send that appeals letter to your provider rep. And sometimes that can work to open up the panel a little bit. And if that doesn’t work, then you just stay in touch. Don’t lose hope. You can still build a relationship with the provider rep by sending kind inquisitive emails every six months or [00:33:00] so. How are you doing? What’s the panel look like? I’d still love to apply. Thanks for considering. That way, you stay top of mind and they will let you know whenever the panel opens up.
The last thing that I want to talk about because this comes up a lot in my coaching and Facebook group is whether you should do all this yourself or have someone do it for you.
In my experience, both anecdotally and literally, the return on investment for having someone do credentialing for you is not worth it. It can be quite expensive. These individuals or groups who do credentialing for clinicians generally are just doing the same thing that you would do as [00:34:00] we walk through in this process. I don’t want to undersell their abilities. Those individuals will have probably some more nuanced knowledge about how to fill out CAQH and maybe they may have contacts with provider reps that can help, but generally speaking, you’re still going to have to gather all of your info, fill out that CAQH application and submit the applications to the insurance panels.
The biggest chunk of time there that someone could do for you is the CAQH application. And at the same time, you are still going to have to gather and provide all of that information to the credentialer. So the bulk of the time I think is gathering the information and making sure it’s in one place.
And then it’s just about moving through the CAQH application. So for me, I lean toward doing it yourself. As I’ve talked about on the podcast, it’s all about [00:35:00] cost-benefit. So if you do the math and figure out that a credentialing service would cost less than the time it would take you to do it yourself, by all means, you can pay someone to do the credentialing for you. Just know that you will have to invest a certain amount of time to even get them up and running to where they can fill out your information. You have to feed them that information no matter what.
All right. So that is the action-packed process of credentialing with insurance panels. If it seems overwhelming, that’s okay. It kind of is overwhelming, but hopefully, this broke it down a little more clearly and made it a little less overwhelming. My intent was to demystify the [00:36:00] process a bit.
I will include links in the show notes to each of the services, websites, and processes that I mentioned. Again, the big ones are getting an NPI number, making sure you have a taxonomy code, getting a tax ID, and then filling out your CAQH application. So all the other things you should have just by virtue of being in practice. So I hope this was helpful.
If you are someone who is at a little further point in your practice journey, so if you’re an advanced practice owner and maybe you are considering taking insurance after being in practice for quite a while, who knows, I’ve run into folks like that. But if you’re an advanced practice owner and you would like to get some support and accountability for making those big ideas come true in your practice, then you might be interested in the [00:37:00] Advanced Practice Mastermind, which, again, as of this recording has one spot available. I don’t know if that’ll be the case by the time it airs, but this episode will technically air before the mastermind starts. So we may have a spot. You can go to thetestingpsychologists.com/advanced and sign up for a free group call to talk with me about whether it would be a good fit.
All right, everyone, stay tuned for the next two episodes. We’re going to be talking next time about billing for testing services and getting paid and getting reimbursed. And then the episode after that, it’ll be talking about requesting raises from insurance panels. I hope that y’all will stick around and make sure to tune in to those episodes as well. Of course, we will have clinical episodes co-mingled in there. So listen for [00:38:00] those as well.
Okay, everyone. I hope you are doing well. Crazy times. Here in Colorado, we have basically resigned ourselves to being in the middle of the apocalypse. We’ve had wildfires raging in our state for the past month. Today it was so dark from wildfire smoke that the street lamps were on and people’s automatic headlights were on as they were driving around. It’s crazy. The sky is this crazy orange smoky, gray color. And it’s pretty unnerving when you layer on top of COVID-19 and school not happening and everything else that has gone on this year. So, fingers crossed that it’s not the [00:39:00] actual apocalypse and I’ll be back with you in a few days. But I hope you’re all doing okay and hanging in there as we head into the fall.
Oh, that’s the other thing. It’s going to snow tomorrow in Colorado at the time of this recording. We have a high of about 90 today. Tomorrow, we’re going to have six inches on the ground. So there’s that too. All right. I am going to stop rambling about the weather and sign off for now. Y’all take care. I’ll talk to you next time.
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