Insurance Credentialing: A Guide to Selecting the Best Networks for Your Practice

By: on April 10, 2019

Figuring out how to get in-network with the right insurance companies is not necessarily something physicians learn in medical school—but it’s a crucial element to running a successful practice. Beyond Medicare and Medicaid, understanding the insurance credentialing process and deciding which private insurance providers to accept will have a huge impact on your revenue cycle and workflows.

When dealing with this (and many other) complex issues related to opening a new medical practice, many providers have turned to Dr. James R. Fedich for advice. Dr. Fedich started his multi-disciplinary clinic in 2004 and has helped it grow as the clinic director since then.

Dr. James R. Fedich

Clinic Director of Village Family Clinic

In this role, he’s had to deal with plenty of insurance carriers—approaching them to join their networks, credentialing, discussing contracts, working through claims processes etc.—and he has some words of wisdom to offer other practices in this position.

With Dr. Fedich’s help, we’ll discuss the four questions you should ask yourself when evaluating insurance carriers for your practice. Here’s what we’ll cover:

evaluating insurance networks

Know Your Practice Needs for Growth

All of the other questions on this list have to do with what the insurance network you’re joining can offer you. However, it’s important to start with this question because it will help you determine your own needs as a practice before you start assessing individual carriers.

Your needs will depend on what stage of growth your practice is in, but the best strategy for new practices is to join as many networks as possible in the beginning and then pare them down over time as you establish your own criteria and expectations. That was the approach Dr. Fedich took when he opened his clinic in 2004.

In the beginning, it’s about getting as many people into your practice as possible.

I was glad I did it this way, it allowed my practice to grow steadily. As the office grew and our patient base grew, I began the process of eliminating insurance companies, or dropping out of networks. This is the model most doctors used when building: Accept most insurance in the beginning, get the practice built up and then carefully reduce their networks.

The name of the game when you first open your doors is acquiring patients, and using insurance networks to do that is a smart play.

There are a few ways to go about identifying insurance networks to join right off the bat:

  • Talk to other providers in your field about which networks they’re a part of
  • Reach out to a consulting firm
  • Task your billing staff with finding and applying for new networks

However, you choose to find these networks in the beginning, remember that your job in the future will be to evaluate each one in order to determine if they’re offering you enough value for your membership. To do that, you’ll need to answer the next three questions on our list.

Know How Many Patients You’ll Help by Joining a Network

The first thing you should check when deciding whether to stay in a network is how many patients you’re serving by accepting this carrier. That means assessing your current patient base to see how many use that insurance.

That’s not to say that number can’t change, as Dr. Fedich knows from experience.

There’s a tiny insurance company in New Jersey. I have never seen anyone in 15 years with this plan, so I never joined the network.

Recently, the big hospital system near my clinic gave their employees this insurance. Not only is that all the employees of three hospitals, it’s all the clinics and centers they own in my area—it’s a lot of people! So, I spent 60 days joining the network since I had a lot of patients that work for the hospital and they had no out of network coverage.

That’s a great example of how an insurance network’s value can change over time, and it really illustrates that, as important as your existing patient base in that network is, it’s not the only factor to consider.

Another thing to think about here is whether or not the insurance network refers patients to your practice. For example, do they have a website for patients with a physician finder that takes location and specialty into consideration before offering a list of recommended, in-network providers to patients?

If the answer is yes, that’s a potential value-add to consider when evaluating that network.

Know Your Cost of Care

The whole point of getting credentialed to join networks with insurance providers is to get paid for the services you’re providing. This means that understanding exactly how much it costs you to work with each carrier and how much they’re reimbursing you for services is a crucial element to judge networks on—whether you’re running your billing in-house or outsourcing it.

It’s also something that Dr. Fedich made a point to call out in our conversation.

Doctors often forget there is a cost to treating a patient, so you have to do your math. If your overhead is $50,000 a month in fixed costs, and you see 1,000 patients—but it costs you $50 to see each patient, and you’re only making $49 on each visit with one insurance—you’re losing money and it’s time to cut and run.

I suggest using key performance indicators to identify costs and keep track of reimbursements from each insurance provider. That way, you can evaluate the costs over time in order to make an educated decision about staying in a network or leaving it.

Know the Hassle Factor

Far and away my favorite thing Dr. Fedich said in our conversation was the importance of something he calls the “hassle factor” when dealing with insurance credentialing.

When evaluating each of the insurance networks we were part of, I asked basic questions like “how many patients did they have” and “what was the average reimbursement per visit,” but a lot of the decisions came down to the hassle factor.

That meant considering things like:

  • Did we have to do a lot of pre-authorization or get prior approval before treatments?
  • Was it ever a struggle to get them to pay our bills?
  • Could I stand to lose the patients in their network?

I like “hassle factor” for an all-encompassing phrase that refers to the level of difficulty associated with working with an insurance provider, and it’s a great thing to call out in your evaluation.

This criteria is especially useful after you’ve been in practice for a while and had time to get to know each of your networks. If, over time, you find that one specific network takes months more than others to reimburse you, that’s a significant hassle factor that might warrant your exit from that network.

Having this subjective element included in your evaluation gives you room to make judgment calls, so you don’t have to be afraid to cut ties with a network that meets your other requirements but still gives you trouble.

Next Steps

Now that you have your list of questions to help understand what goes into insurance credentialing and better evaluate insurance networks, the next thing you need is data.

Come up with a way to track interactions with each insurance network you’re a part of and note the pros and cons of working with each. Whether it’s something as simple as a spreadsheet or a more complex revenue cycle management system with reporting functionality, just make sure you’re taking notes to help make these decisions when the time comes.

For more information about software that can help with your medical billing processes, you can reach out to our team of advisors to receive a customized list of software recommendations based on your needs.

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