The provider enrollment process for a physician or provider is different based on the payer and the type of provider.  There are typically around 20 different insurance plans in your region so before you begin, it’s important to check with current or potential referral sources to ensure your plans match theirs.  This will improve your chances of obtaining referrals as they won’t have to check if you participate each time they want to send you a patient.  Once you’ve identified your list of plans, you now need to get your CAQH profile set up and start contacting the payers or contact a company like ours and outsource the entire enrollment and contracting process.  We handle all of the insurance applications, your CAQH profile, PECOS, NPPES, credentialing follow-up, and contracting so you can focus on things that you can do more efficiently.  We handle the credentialing process for thousands of providers each year and would love the opportunity to help you.

Listed below are a couple key distinctions within the credentialing process that are important to understand as you start down this road.

Different Credentialing Processes depending on specialties

A psychologist may go through a national credentialing company or TPA like Psychcare which would handle the credentialing for multiple plans that Psychcare is contracted with.  Physicians however, would go through each company such as UHC, BCBS, AETNA etc unless they decide to contract through an IPA. It’s important to understand the inner workings of an insurance plan if you’re hoping to become in-network.

Psychcare is similar to a TPA(third party administrator) or IPA(independent physician association) if you’re familiar with either of these.  The psychiatrist would still need to negotiate his/her contract with a company like Psychcare but this agreement will include rates for a number of different plans.  A physician would go through UHC directly and the contract with UHC would only include fee schedules for UHC plans.  Physicians would go through a local contracting representative that works specifically with this specialty rather than the whole state.  It’s important to remember that medical is handled in a different department than behavioral health and other ancillary divisions like ASCs.

The commercial insurer process involves credentialing (primary source verification, CAQH credentialing) and contracting which would include the contract negotiations; whereas with straight Medicaid or Medicare, they only need to be credentialed (Except where Participation vs Non Participation is concerned with Medicare).  

We are only speaking of straight Medicare and Medicaid, not the HMO plans which actually can be negotiated (this fact is often overlooked).  Unfortunately, Medicare and Medicaid have established fee schedules which are non negotiable.  With most of the commercial payers and HMOs, their fee schedule is set as a percentage of the current or prior year Medicare fee schedule.  

This is why cuts to Medicare are so impactful, even when a provider is not a Medicare provider.  When reviewing your commercial insurance contracts, you have to look at the year Medicare fee schedule the plan is wanting to put you on.  This is another reason why it is so vital to have an expert assist you in selecting evaluating your payer mix and negotiating your contracts.

Difference Between Commercial Insurance Contracting & Medicare Enrollment