When you join an insurance panel for the first time, you’ll go through a process called credentialing. It is during this process that your contracted rate is determined. A contracted rate—also known as a negotiated rate, an allowed amount, or an agreed upon amount—refers to the amount an insurance payer agrees to reimburse for your services.
To become an in-network provider for an insurance company, you must first apply online by visiting the insurance company’s website. After you apply, it’s important that you fill out a Council for Affordable Quality Healthcare (CAQH) Pro View Application. The CAQH is where you will self-report your education, training, and experience. It may seem like a long and tedious application, but unless your information changes, you will only have to fill this out once.
If you’re not sure which insurance companies will be the most valuable for you to partner with, think about the population you are most interested in servicing and also consider the dominant employers in your area.
Do some research online or reach out to a colleague to find out what insurance they offer their employees. If a large percentage of your surrounding area is insured through Medicare or Medicaid, consider joining those panels. We also recommend researching which insurance payers have the most competitive reimbursement rates in your area.
When you verify a client’s insurance policy, you may find that a prior authorization is required. A Prior Authorization, also known as a “pre authorization,” or “pre certification,” indicates that you must obtain consent from the insurance company prior to any services taking place. Insurance companies will often request a referral from your client’s primary care physician, current diagnosis, planned treatment services, and medical information about your client to determine medical necessity.
Understanding the difference between diagnostic and procedural codes is the first thing that you should know. ICD-10 codes, International Classification of Diseases, are used to diagnose a patient’s condition. You must have the proper documentation to support this diagnosis. In cases where you were not the one to diagnose the client, you will need to know who the diagnosing physician was that gave the order for your client to receive the services that you provide.
To learn more about getting started with insurance, download your free version of the ebook today.