There is a bit of a shift in commercial insurance contacting of which you may want to be aware. If you are an established provider with established contracts, there are still some changes we have seen that could impact you. If you are looking at starting a practice, then we definitely have some information you should consider; if you are looking for money to start your business visit this site now. First though some nomenclature to help lessen the confusion.
Contracting vs. Credentialing – These terms are not synonymous. Credentialing is the process by which the insurance carrier decides if you are eligible to be a participating provider. They are looking at any malpractice concerns, lawsuits that may have been settled, your board certification and status, and any other elements in that vein. Contracting is the process by which the practice (company) is offered an agreement including terms and rates. If you are opening a new practice, they will initiate credentialing first and then, if all is fine there, begin the contracting process. The entire length of time this takes is anywhere from three to nine months dependent upon the payer.
Contracted and Credentialed – Especially if you are starting up a new practice, be very careful to ascertain if your new practice is contracted. All too often the payer will note that Dr. ACB is credentialed and allowed to see patients. This is true… if they were still seeing patients at their old practice. The contract is by and between the payer and your corporation. I would double check to ensure this is the case.
Nervous Payers – With the possible repeal and replace of the Affordable Care Act with a still unknown piece of legislation, the commercial insurance carriers are very unsure as to what they should be doing over the next few years. They do not know if they should be trying to grow their business, hire more staff, or move into new products or markets. This uncertainty is leading to some negative outcomes for the small provider community.
Rate Trends/New Practices – It has not been uncommon in significant retirement community areas (south Florida and Phoenix) for contracts to be sub-Medicare in reimbursement. We are now seeing this trend of sub-Medicare reimbursement in the Atlantic coastal states and Texas. If you are in the process of obtaining new contracts, be sure to push for the actual fee schedule of key codes. The payers have, intentionally I believe, left language in the agreement that is beyond vague such as: 105% of the XYZ Insurance Fee Schedule. It sounds fine until you find out the XYZ Insurance Fee Schedule amounts to 80% of Medicare.
Rate Trends/Existing Practices – Some payers have, over the past few years, sent notice to providers stating that the contracted fee schedule will be reduced – typically to 100% of Medicare but sometimes worse. Unless you are providing some additional services beyond varicose vein treatment that is needed in the community, it is very difficult to push back on these reductions.
No Contracts/Termination of Contracts – In a number of areas, it is difficult at best to gain a new agreement with some of the payers. If you are starting up a new practice, I would reach out to the key three or four payers in your area to determine if they are indeed contracting with new providers or if they are a closed panel. We have likewise seen some payers terminate their agreements with in-network providers for essentially no reason in order to ‘narrow’ their network. This termination process has not happened that often but it is something to be aware of at the very least
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