Submitted on Mon, 2015-08-03
By SMART Health Claims

Dell Snellings, a public health medical billing expert, explains the inner workings of the credentialing and contracting process as well as the barriers along the way.

The Affordable Care Act has transformed the healthcare landscape in many ways, but for Local Health Departments (LHD), it has opened new revenue opportunities that could offset funding cuts. In today’s healthcare environment of declining funding, LHDs must find new ways to capture revenue and ensure it is received promptly for services provided to the community. One way to increase revenue opportunities is to become credentialed as a specialty network provider with insurance payers. Private insurance companies use the credentialing process to obtain, verify, assess, and validate a health clinic to make sure they are a reputable facility and for liability purposes. 

We sat down with medical billing expert, Dell Snellings, who served as the lead consultant for Upp Technology’s contracting and credentialing project for the Houston Department of Health and Human Services. Ms. Snellings masterfully explained the inner workings of the credentialing and contracting process with insurance payers, as well as the barriers along the way.

The process of registering as a specialty provider is a complex one, requiring an extensive time commitment from LHDs. “It’s very important to note that insurance payers are required to have a certain percentage (roughly 30%) of specialty providers on record in order to maintain their Qualified Health Plan (QHP) status,” she said.  “Insurance companies are just beginning this process, so there are very few guidelines in place, creating the perfect opportunity for health departments to apply for network participation.”

Before embarking on this process, Ms. Snellings noted that it is imperative for LHDs to ensure that internal processes and workflows are in order so they can effectively capture revenue once they are approved.Additionally, it is essential to establish a contact person to manage communication with payers and field questions to keep the process moving forward. 

3 Roadblocks for LHDs Registering as Specialty Providers with Insurance Payers

1) Collecting and submitting accurate (and often personal) data

Players require a high volume of information – some of it personal – as part of the application process. The required documents for this process could include a provider’s medical diploma, state license, DEA certification, CDS certification, and professional liability information. 

Private insurance payers utilize the Council for Affordable Quality Healthcare (CAQH) database, a universal catalog that serves as a “background check” system, to verify information submitted on applications.  While some local health departments may find the release of personal information unappealing, it remains a universal requirement that payers must receive to begin the consideration for a network contract. 

Once all of the necessary information is provided to the payer, local health departments should begin setting up profiles for each provider on the CAQH database. This is done by filling out an application at caqh.org.

Following the completion of the application and confirmation that all information is accurate, the contracting process begins.  Stay tuned for our follow-up post on this topic, which will focus on the comprehensive checklist of what needs to be approved during this process.

2) Reviewing and returning the contract in a reasonably timely manner

Once the application is verified for accuracy, LHDs can begin contract discussions with insurance payers. Next, the insurance payer will draft the contract for the local health department and send it to the LHD, at which point the LHD legal counsel should review. 

Contracting is the process of setting up agreements with the insurance company to become in-network with them; establishing rates, services covered, the timeframe a payment will be received, and other information with each payer.LHDs will need to set up a separate contract for every insurance company they plan to bill. A payer-created contract is a standard contract with universal language, so LHD may find it an unwise use of health department time and resources to suggest extensive alterations to the contract language.

It is crucial to understand that the contract must be returned to the payer within a reasonable amount of time, or the file could be closed

3) Preparing for the unpredictable approval process

The payer approval process for a network provider application is notoriously lengthy (approximately 90-180 days).  The insurance payer Board reviews all applications and if they are not submitted correctly and within guidelines, they will be rejected.  However, even if all of the information is submitted correctly, LHDs must be prepared for curveballs. 

For example, if a doctor has not billed Medicaid in a significant period, they could be deactivated from Medicaid.  If they are an out-of-network Medicaid provider, the payer must halt the approval process until the provider re-registers with Medicaid and becomes active again. 

What should LHDs understand about the approval process

The payer landscape is unpredictable, and communication delays are inevitable, given the universal nature of contracts and the individual needs and limitations of LHDs.  The road to becoming a network provider is long and often bumpy but not without benefits once the destination is reached.  With the right amount of organization and persistence, LHDs can begin billing immediately after approval is granted and will realize dividends for a long time to come.

Have more questions? Schedule a meeting or speak with one of our public health billing experts and stay tuned for the follow-up post on this topic where we’ll help you prepare your network provider document checklist.

Innovative Technology Solutions