Healthcare credentialing is challenging for physicians and healthcare organizations alike. Physicians graduating from training programs have little knowledge about the ins and outs of credentialing with insurance companies and often leave this process to others. In this episode, Coach JPMD describes three necessary steps that physicians should follow in order to get paid. He also details why it is important to not sell yourself short when negotiating with insurance companies. Stay tuned until the end to get access to a free course and checklist.
Don't forget to subscribe/follow the Practice: Impossible podcast on your favorite app.
Welcome to the Practice Impossible podcast where you host, Jude A., Pierre MD, al o known as Coach JPMD, discus es medical practice topics t at will guide you through the m ze that is the business of medicine, and teach you how to increase profits and h lp populations live long. Y ur mission, should you choos to accept, is to listen a d be transformed. Now, here's your host, CoachCoach JPMD:
Welcome to this week's episode of the practice impossible podcast where your hosts, me, Coach JPMD is going to discuss the first steps of getting paid and what it means to be credentialed in healthcare. So before we get into the steps, I wanted to kind of go over where we come from as physicians. We go through four years of college, four years of medical school, with over $200,000 in debt on average, and then we enter a contract in residency for three to seven years as indentured servants. And yes, I said indentured servants. I actually looked up the definition of what an indentured servant is. An indentured servant willingly enters an agreement to work for a specific period of time, up to six years or longer, in exchange for something. Now I'm paraphrasing this from reference.com. The contract of an indentured servant can be sold to an interested party, but the servant is not considered the property of the contract holder. Once the indentured servant is released from his contract, at the end of the term, it becomes a recognized part of the physician community, I added that. So after we've gone through our residency training program, then what? Well, we have to get a job. And in order to get a job, the person that's hiring you, whether it be a private practice, the hospital system, or if you're going to be a consultant, you actually have to be credentialed in order to receive payments from any healthcare organization. So I want to go over the definition of what healthcare credentialing is. And it's a process of gathering and verifying healthcare providers, qualifications, degrees and background for the purpose of confirming legitimacy. So if you're going to see patients and get paid, you have to be credentialed. So that is the first step. And that's true for whether you're going to see patients as cash pay, or if patients are going to come to you and pay you cash. Or if you're going to be an employed physician by a large healthcare organization. If you're going to have a solo practice, you have to credential or be credentialed to see patients under the specific insurance companies. And if you're a consultant, you want to be on as many plans as possible in order to see patients that may have the insurance that is prevalent in that community that you're working in. So in addition, what I do, is see patients that are typically over the age of 65 and most of those patients will have Medicare and or Medicaid. And so in order to see those patients you have to be credentialed with Medicare, Medicaid, and you have to go through a credentialing process. That's the same with Blue Cross Blue Shield, United Healthcare, Humana, Tricare, Aetna, Cigna, all these insurances are, in order for you to get paid. In order for you to see patients and be recognized by that insurance company, you have to go through a credentialing process. So some of those insurance companies that we mentioned, or that I mentioned, are either private pay, government pay, or a hybrid. And so what hybrid plans are, are they're private organizations that contract with the government in order to see patients. And those include Medicare Advantage plans, like the Humana's of the world, or Wellcare, or Centene Health, or Optimum Health Care and Ultimate Health Care. These are insurance plans that contract with the government in order to provide care for a particular patient population. But even before you have a chance to see those patients, it's really all about the numbers. So you have to have certain numbers and certain, for lack of a better term, it's really numbers. It's the NPI number, the National Practitioner Identifier. That's a number that we all have as physicians and are required to have in order for us to see patients or be credentialed with any of these insurance companies. Then you have to have a Medicare number. A Medicare number is a number that you use to submit to health plans to let those health plans know that you are able to see patients under government plans. So now I know this all sounds super complicated and applying for different healthcare organizations and different numbers and Medicare numbers. And I want to tell you that if you guys listen to the end, or see the show notes at the end, I'm going to give you an opportunity to actually sign up for a healthcare credentialing course that I created. That details all of this, what we're talking about here, as well as provide you with a checklist. Especially for new physicians coming up. It's important to know what you need in order to to get credentialed with these insurance companies, especially when you're first starting out, because the more plans that your you're on, the more opportunity you have for increasing your patient population. So, first step is get credentialed, get your numbers and the NPI number, Medicare number, Medicaid number. And then once you have those numbers, you can then go to individual organizations that you want to be a part of, if you're a solo practitioner, or consultant, and you apply, and there is a centralized application process that we all go through. And it's called that the CAQH portal for lack of a better term. And so that portal allows physicians to enter all of their numbers, their NPI numbers, a DEA numbers and their practice locations. And a CAQH stands for Counsel for Affordable Quality Healthcare. And what they do is they collect information, they store the data, and they distribute it to all these health plans, so that you really have one place to go to start that credentialing process. And then from there, you decide what insurance companies you want to contract with, and you send them your credentials, and then they send you back a contract. But it's not about sending your applications to every single insurance company out there. Because some insurance companies may lowball you. I had an insurance company one time came to me probably about four or five years into practice and they said that they had a large patient population in the Spring Hill area in the community and they wanted me to see their patients as a primary care physician. So they came and told me that in the contracting and negotiating process, they said, "Hey, you know, what? We have this large population of patients and we want to give you 80% of what Medicare would give you". And I said, "Why would I accept that?"... "Well, because we have a large population of patients, and we want to be able to give you a steady stream of patients coming from our insurance company". And I said, "No, why would I credential with you and accept less money than what Medicare would be giving me?" So we negotiate back and forth. And finally they came back and said, "No, well, we'll go up to 95% but we can't give you 100%." And for some reason, they stuck with that 95%. And I decided not to accept that insurance because you have to know what you're worth as a provider. And also, if we as providers don't stand for at least a bare minimum of what we would want to accept, and I feel that the Medicare fee schedule is probably the bare minimum, then we shouldn't accept it. But that also applies to insurance companies that you do accept. I remember in probably about the same amount of time, five, six years into practice. I was seeing a lot of patients in one particular insurance, I was also doing managed care. So in managed care, we see patients regularly and but with some of the managed care programs that we see, actually, all of the managed care programs that we see we see receive a capitated check every month, whether we see the patients or not, as long as we manage their care, we can do very well. So I was chugging along, growing my panels, and was noticing that I had a fair number of patients occupying my schedule that were in a particular insurance plan. That was a fee for service plan. So we can talk about that and I described that in another podcast, differences between fee for service and Medicare Advantage, and captitated Medicare. And I ran the numbers. And for the 100 or so patients I was seeing under that plan, because the contracted rate was maybe not as good as other plans. I was making I think 12,000 or 15, I think it was about $15,000 for the year in managing a very sick population of patients under a certain plan. And I realized that it was not to my benefit from a business standpoint, to continue managing that group of patients because the reimbursement was low, So I decided to renegotiate the contract. So once you are credentialed with an insurance company, you can decide not to accept it. And you can also decide to renegotiate a contract or maybe even stop taking an insurance company because it is not beneficial to your objective in your practice. And I know I may be sounding like someone that's trying to cherry pick. But I think as physicians, we need to understand what our worth is. And we need to understand contracting and negotiating contracts. And if something is not working out for you, then you should have the ability to make the choice to either not accept the insurance or renegotiate rates. So some of you may be part of a large healthcare organization, and maybe actually administrators listening to this podcast and saying, "Hey, you know what? Physicians should be doing all of this. They shouldn't be getting their numbers and, you know, we have people in our organization that can do this for you". And what I say to those administrators and what I say to physicians who feel like they shouldn't be doing this is...You know, if you, if you were a store owner, if you owned a shop or grocery store and you owned, or you owned a car dealership, you would not outsource your credit card machine that accepts payments to your business to an external source. You would want to know what the rates were, how those monies are coming in, and who's providing those services. So I really think that physicians need to understand that part of the the business of medicine because you wouldn't outsource the money collection process of any other business. So as a healthcare provider, I think it's important for you to, to understand that, in addition, you may not be with that organization later on, you may not be with them for two, three years down the line. And then if that organization has all your logins and all your credentials, and you are leaving that organization, guess who you're beholden to? You're beholden to that organization who's going to have that information. So now, I'm not saying that you need to maintain it. And it may be too difficult for you to kind of manage all of that initially. Sorry, not initially. I mean, it is not too hard to manage it initially. But to maintain it, I think it's important for you to actually understand where those logins are coming from, how you can change things if you need to, if you're not working for that organization, and it really puts you in the driver's seat. With that comes with step three. And that is what we've just spoke about, what I just spoke about, and that is the maintain your own login on CAQH and review that regularly. The key is to make sure that all the information is up to date, because if the information but let's say about your practice is not up to date, or your office phone number is not up to date, then patients won't be able to find you. So it's very important to maintain that. Maintain what insurances you accept, maintain any associates that you might be hiring into the practice, and make sure those things are up to date. So as new physicians coming out of residency and fellowship, I felt it was really important to give them a resource that can help kind of navigate this whole process. And so what I've done is I've teased out the healthcare credentialing course out of the comprehensive course at Learnaboutmedicareadvantage.com. And with that, you'll be able to also download a checklist that will help you understand all the processes with regards to getting your numbers, your logins, what website to go to for the majority of the insurance plans that you want to credential with. And so if you go to www.learnaboutmedicareadvantage.com and hit the sign up button, you've got a login page and enter the coupon code ("PI") P as in practice, I as in impossible, FREE, and that will get you right into the credentialing course for free. And you'll be able to download the checklist as well. So that's PIFREE coupon code. And that will get you right into the credits and course for free. And know that, you know, my goal is to help physicians Practice: Impossible. And one of the things that they need to do is get their credentials in order. And that's the first step to getting paid. And with that course, and the checklists, I think that will just make this process just a little bit easier for you. And please leave a comment and subscribe to my channel because my objective is to continue to give more and more information to help physicians in the practice of medicine, not only just in the practice, but also in the spiritual and mental and physical realm as well. Because I think that's the only way that we're going to help our patients live long. That is, if we're not stressed and burnt out, and we have the right resources and the tools in place to help us practice powerfully. So thanks for listening to this episode on the first step to getting paid and I look forward to continuing to serve our physician population for many years to come.