Credentialing is the fun process of becoming an in-network provider with insurance companies. I say fun with a very heavy air of sarcasm. I would compare the process to be as fun as waiting in line at the DMV on a Saturday morning. However, at least in that scenario while you may wait forever and be directed to various lines and people; at least in the end you get what you want. That unfortunately is not always the case with trying to become a contracted provider with various insurance companies.
If you anticipate to bill insurance you will likely want to start the actual credentialing process at least 6 months prior to seeing your first patient. Insurance companies can take an upward of 60 days to review your application. Plus, if anything is missing including both information and/or documents the company may deny your application further delaying the matter. Therefore, my words of wisdom are to start early and be patient.
Let’s lay down a couple of ground rules when it comes to health insurance:
- Each state determines the range and extent of specific services covered
- Each state has different insurance companies
- Each insurance company has varying amounts of coverage for MNT including patient criteria, visit criteria and filing processes
- Each insurance company provides varying amounts of reimbursement to RDs
This basically means that when it comes to third-part insurance companies there is no uniform coverage or payment to dietitians. Some insurance companies will cover two visits per calendar – while others will cover unlimited visits depending upon how the visit is billed. To complicate matters further coverage may also vary provided for the same insurance company.
For example, I personally have Anthem health insurance (through the exchanges as I am self-employed) and on my particular policy I only have two covered visits per year to see a dietitian. However, many of my patients also have Anthem but they have unlimited visits as long as we code as preventative. So go figure!
Step 1 – Determine the insurance companies in your state
Now, let’s get to the real fun stuff – determining which insurance companies you should get try to get credentialed with. I say try because not all insurance companies are open to new dietitians. We will talk more about that later.
Some of the major national plans include Aetna, Blue Cross Blue Shield, Cigna, United Healthcare and Humana. However, as noted earlier, this varies state-state.
In Connecticut we currently (2019) have the following insurance companies:
- Anthem Blue Cross
- Harvard Pilgrim
- United Oxford
However, if you live in Florida or California you likely have a very different mix of insurance companies as well as laws and regulations governing medical nutrition therapy.
Therefore, the best way to determine what insurance companies are in your area is either to ask another seasoned private practice dietitian in your state – or reach out to the reimbursement representative for your affiliate of the Academy. This person is usually listed on your affiliate’s website. For CT, I am actually the Reimbursement Representative and I always happy to help with this piece of the puzzle when I can.
Step 2 – Reach out to each insurance company individually
Each insurance company has its own credentialing process. Once you know who the major insurance companies are in your state then you must decide which ones you want to become credentialed with. I might suggest starting with a couple of carriers in an effort not to overwhelm yourself.
Once again speak with local dietitians and see which insurance companies are easiest to deal with, provide great coverage and prompt reimbursement. After you decide this information you must then reach out to each insurance company individually and request an application to become an in-network provider.
Start by calling and ask the provider services contact whether the insurance company is currently accepting new dietitians in your area. Some insurance companies limit the number of dietitians who they allow to participate as in-network providers in a certain geographical area. Generally, the larger the enrollment of patients in a particular region the wider the network.
If the network is open to dietitians then the provider relations will either send you a contracting by mail or by email. Or they may direct you to a link on their website where you can download and fill out the information. In addition to their contract, they will likely request your CAQH number so they can access your CAQH application.
The contracting turnaround time varies depending on the particular insurance company. Some companies contract quickly in as little as one month, and some may take as long as six months. Unfortunately, I have only personally experienced the latter. It seems pretty common place for the whole process to take about 4-6 months when all is said and done.
Next step – signing your contract.
What do you do if they tell you the network is closed to new participating dietitians?
I have had this experience with two insurance companies in CT. Both times I was told that the market was saturated with dietitians. Over the course of the last 5 or so years, I appealed these denials several times by writing certified letters and documenting strong reasons for them to accept me into their networks. Unfortunately, despite appealing, I have not been accepted to be an in-network provider.
However, this does not mean YOU should NOT appeal if you are initially rejected. Can you make a good case why the insurance company should accept you into your network? Do you offer a specialty that the others in-network dietitians don’t currently offer? Do you hold a board certificate or degree that makes your skill set unique? Is your state large? Do you feel that the current participating dietitians are not in your geographical area, therefore, leaving a potential gap in coverage? It never hurts to try!
If you do decide to appeal the decision you can generally get the appeals address from the provider relationship representative. While they are not always so happy to provide it – they generally will after some prodding!
I would highly recommend keeping copies of your letters and even sending the letters via certified mail. That way you have confirmation that your letter was received.