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Applying For Medical Panels

Aaron Lech, O.D., F.A.A.O.

Applying For Medical Panels

All you need to know about the typical timing and process of applying to be on a medical panel.

Becoming paneled with most medical plans is basically a 3 step process: application, credentialing and contracting. Frequently, the entire process takes between 60 and 180 days to complete. In order to expedite the process it’s best to respond promptly to all information requests, and whenever possible do so electronically via direct upload, email, or by fax. While a majority of the information needed to complete the process is similar across all plans, each one does have its nuances with relationship to both the requirements and the process.

GETTING STARTED

From the outset, each provider should compile a short list identifying the panels they hope to become contracted with. To do so, it’s imperative to understand what possibilities even exist. In most states, commercial plans are regulated by the state department of insurance. Government programs such as Medicare and Medicaid comprise the remaining segment of the market. Given our healthcare system’s deepening connection to Medicare and Medicaid with ACA implementation, providers should seriously consider adding Medicare to the top of their list and need to stay tuned regarding Medicaid, as it will have a much larger effect on the system through the exchanges.

GETTING PREPARED

One key to being successful at this in your state is knowing which plans or entities cover lives in the practice’s immediate geographical reach. Sources for this information may include other providers (ODs, MDs, group practices), employers in the area and/or a multiple-month survey of patient’s medical cards. This list of medical plans should serve as the master list for each practice or provider.

Before beginning, each doctor should compile a list of information commonly requested for credentialing purposes. These include items such as a copy of each doctors state license, DEA registration, IRS EIN verification letter, voided check, business license, Type 1 NPI (Individual) and typically Type 2 NPI (Group) in addition to verification and a full genetic map of your family tree (just kidding). Typically each commercial and government plan has a detailed list of what documents they require online.

APPLICATION

After identifying the plan(s) to target and compiling the necessary documents/information you are ready to begin the application process.  For most PPOs and Medicare the application process is typically online.  In some cases the provider must first fill out an application request form that is submitted electronically.  They will respond indicating whether or not they are accepting provider applications at that time for your region.  In other cases (such as Medicare), doctors or their staff can submit a fully completed application (either online or via the mail)  that will serve as a credentialing contract online.

CREDENTIALING

Certain health plans use CAQH, www.caqh.org to catalog and verify provider credentials.  United Healthcare and First Health are examples.  Optometrists looking to contract with these payers should obtain a CAQH number and submit their information online to be viewed by interested contracting companies. Other payers will ask you to submit documentation directly to their credentialing department (not contracting).  As an example, Blue Shield of California maintains separate credentialing and contracting departments in different cities.  Finally, medical groups and IPAs will often have their own credentialing departments maintained by a management services organization (MSO).

Once a doctor has received confirmation that a medical panel is accepting provider applications and has submitted credentialing documents via the appropriate channel(s), processing usually takes 60-90 days.  If a medical panel is not accepting new provider applications, contact them regularly to inquire if this status has changed.

CONTRACTING

Once your application has been processed, and if approved, a contract will be sent for review and signature.  Although the emphasis of this article has to do with the process of applying for medical panels, a provider should always be sure to review all contract terms and how these may be beneficial or detrimental to a practice.  Seeking advice from colleagues, especially those who are contracted with a particular payer for multiple years, can be beneficial at this stage.

SUMMARY

Preparation, attention to detail, and determination are the basic building blocks of becoming paneled with medical plans. The process is not always straightforward and can be fraught with moving targets. Some providers might be up for the challenge of going through the process on their own, recognizing from the outset that it will require some of their precious time, even if they expect their lead staff to handle most the process. Others surely realize a real benefit in outsourcing the application/credentialing process, allowing them to focus on what they and only they, can do best.

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