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Credentialing: What is it, and why is it important?

Updated: Jul 25, 2023

Unlock the Power of Medical Credentialing: Gain Reimbursement and Expand Your Practice with Insurance Panels


Credentialing is a necessary process for healthcare-licensed professionals who intend to submit healthcare claims to insurance payers and receive reimbursement for their services at a predetermined rate. Moreover, being part of an insurance panel as an "in-network" provider offers additional advantages, such as referrals and preferential reimbursement rates.

Once a healthcare provider completes the credentialing process with an insurance company, they gain the ability to directly bill that company for their services.

This process typically involves two phases: credentialing and contracting. During the credentialing phase, the insurance panel verifies the provider's qualifications and conducts primary source verification to ensure they meet the panel's minimum requirements. The panel may also access the Council for Affordable Quality Healthcare (CAQH) to review the provider's educational and employment background. After completing the credentialing phase, the provider's application is forwarded to the contracting phase. At this stage, the provider and their practice may be offered an "in-network" contract with the panel, which typically includes the fee schedule and eligible CPT codes for billing.

In today's medical marketplace, accepting patients' insurance plans is crucial for the success of healthcare practices, regardless of their size. If potential patients are unable to utilize their insurance plans at a particular practice, they are more likely to seek services from competing providers who do accept their insurance.

The demand for insurance plans stems from various factors. Over the past two decades, more people in the United States have obtained health insurance, which now provides coverage for previously excluded pre-existing conditions as mandated by law. Insurance plans also offer "mental health parity," ensuring coverage for mental health counseling and psychiatric services. However, there has been a decrease in the availability of "out-of-network" benefits in insurance plans. Consequently, patients now predominantly seek providers who are part of their insurance plans' preferred provider list to avoid significant financial penalties.

As health insurance plans have expanded their coverage to include a broader range of services, medical credentialing has become increasingly valuable. These changes encompass mental health and behavioral health parity, fewer restrictions on pre-existing conditions, and coverage of supplemental services like physical therapy, massage therapy, and acupuncture. However, the cost of health insurance in the United States has also risen, prompting individuals to heavily invest in their health insurance plans. When individuals require healthcare services, whether general medical care, emergency medical care, dental, chiropractic, optometry, or mental health services, they prefer and expect to use their health insurance plans.

Unfortunately, as more healthcare professionals seek to join insurance networks, these networks are becoming increasingly full or even closing. Consequently, the process of medical credentialing is becoming more challenging. However, some panels claiming to be "closed" are simply highly selective in their provider additions. Knowing how to position one's practice and expertise can greatly enhance the chances of being accepted into these "closed" panels.

B.T. Elite possesses extensive knowledge of the licensure process for behavioral health providers, including Licensed Professional Counselors (LPC), Licensed Mental Health Counselors (LMHC), Licensed Professional Clinical Counselors (LPCC), Licensed Clinical Professional Counselors (LCPC), Licensed Independent Clinical Social Workers (LICSW), Licensed Clinical Social Workers (LCSW), Licensed Psychologists, Licensed Marriage and Family Therapists (LMFT), and others. We understand that a designation in one state, such as LPC or LCSW, may not be recognized as the same level of certification in another state. Therefore, we can assist you in navigating the challenges posed by these variations in nomenclature.

At B.T Elite, we provide Medical Credentialing and Provider Enrollment services every year to numerous healthcare practices and providers across the United States, spanning from New York to Alaska and Hawaii. Our services aim to help these entities become credentialed with the best third-party payers.

Whether your healthcare practice aims to join the preferred provider network with Blue Cross/Blue Shield or seeks to be paneled with Medicaid, our highly trained credentialing specialists are equipped to assist you. Our services include individual provider enrollment/medical credentialing (getting on insurance panels), group provider enrollment, CAQH completion and management, and credentialing.


We cater to healthcare companies of all sizes, from solo practices and physicians to dentists, psychology counselors, physical, occupational, and speech therapists, group medical practices, large medical centers, healthcare facilities, DME companies, and home health agencies.

If you desire a medical credentialing service that can alleviate the burden of getting on insurance panels, we invite you to consider our trusted and effective credentialing service at www.btelite.com. We have successfully helped numerous providers and practices with their credentialing needs, and we would be delighted to discuss how we can assist you. Don't hesitate to call us at (470) 394-9153.


 

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If you are a healthcare professional or a healthcare practice that can benefit from credentialing, billing, denial management, or training, Please contact the healthcare revenue experts, B.T. Elite at....



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