Episode 6: Credentialing And Contracting

The Private Medical Practice Academy

Episode 6: Credentialing And Contracting

October 20, 2020

Episode 6: Credentialing And Contracting

There always seems to be a great deal of confusion about credentialing and contracting. In this episode, I'll talk you through the differences and give you some pearls on navigating the "system." Really–it is very straightforward. 

  • If you are all Cash Pay–you don't need to worry about being either credentialed or contracted.
  • Credentialing is the equivalent of the good housekeeping seal of approval. It means that the insurance company "recognizes" you. It has absolutely nothing to do with money–meaning how much the insurance company is going to pay you. 
  • You need to be credentialed regardless of whether you plan to be in network or out of network.
  • You can use CAQH Pro to apply for credentialing with multiple insurers–and it's a free service. Here the link:
  • Get all of your documents together before you even start–this is the part that takes the longest time. 
  • Here's a list of the documents/info you need to get started:
    • License to practice
    • DEA and CDS certificates
    • Education and training 
    • Board certification
    • Work history
    • Malpractice history (NPDB)
    • License sanctions (NPDB)
    • Medicare/Medicaid Sanctions (NPDB)
    • Hospital privileges
    • Current malpractice coverage
  • If you are going to be out of network, you do not need a contract. You only need to be credentialed.
  • If you want to be in network, you need to have a contract.
  • Many insurers will allow you to go through the credentialing and contracting process simultaneously
  • Credentialing and Contracting take a long time–way longer than you think (like 3-6 months)–Plan ahead

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