Insurance data for new health care practices

Time after time, new practices invest countless hours and focus on office space, equipment, software, and personnel, only to open their doors to business and suffer significant delays in obtaining substantial insurance benefits.

More often than not, the problem could be overcome by quickly and completely tackling the insurance identification process, creating the necessary relationships with insurance companies. Here are some considerations to keep in mind when handling the insurance credential process.

Time – Start early!

Plan to start the insurance certification process sooner – allow at least six months before seeing your first patient. The carrier needs 3-4 months to review the documents and make a decision, even if everything is fine. If there are errors, several more weeks or months may also be added to the process, a question about missing information or the document presented. This six-month allowance, from the moment credentials are awarded, usually provides sufficient time to address any issue. If very little time is allocated before the commencement of practice and you begin seeing patients before the insurance reference is completed, you are made aware of the risk of receiving an ‘out of network’ rate, reimbursement sent to the patient You can go, or, in the worst case situation, that you don’t get at all.

Identify target carrier

To determine which insurance policies you log into, consider your practice location and patient demographics. Will a significant percentage have Medicare or Medicaid? Is there a particular company or business in the area that employs a large portion of the surrounding population? A quick phone call to your HR department to find out what insurance policy they currently provide to employees (and possible changes in the near future) can be a good indicator of the carrier you consider.

Also get in touch with colleagues, other providers, clinics and even larger hospitals and ask who are their highest paid. Find out which payers can work best – who pays on time, which registrations are the largest and which carriers may be with other providers in your area.

List the top 10 or 15, identifying which insurers are most popular in the area. Then think about what other providers are saying and put that list back in the top 7 or 8. This will be your short list of where you need to go. Don’t go overboard and pick up many from the start – if nothing else, you’ll ridicule yourself for having presentations.
Contact insurance companies

With your list of 7 or 8, prepare to spend at least an afternoon (or more) on the phone with the service offices of all your target providers.

One of your first questions may be to ask if they accept your specialties in your field. More often than not there is no problem here, but don’t be disappointed if they say no – just keep scrolling through the list and prepare to come back with them for an opening later. (Remember that if multiple providers on your list indicate they are closed to new providers, you may want to reassure your location before continuing – multiple providers closed for new practices in the same region Is a strong indicator that a lot of the competition has a pass.)

If the carrier is open to new providers, make sure that you get all relevant information about the process – namely names, addresses, phone numbers, times, required forms, and so on. Also, do not forget to ask about online submission, because nowadays many providers can give you all the information in the supporting documentation online and via post.

** Please note that carriers will not begin the insurance reference process until you have established a practice phone number and address (PO boxes are not acceptable). If you have set a practice address, but have not yet moved, carriers can usually send the form to an alternate address, but you will still need to identify the location to start things.

Submit reference

Now that you have completed your investigation and identified which insurance companies you are applying for, you should collect all your information. Most commonly you will need to provide the following:

Updated cv

Personal demographic information

Practical and Business Information

State and Federal DEA Number

State License and Registration Information

Evidence of training – ie diploma or ECFMG certificate

Information about misconduct

Information about any disciplinary action
While this can be a lot, there’s good news – since most providers ask for the same information, once the first submission is complete, you can transfer all the details from one form to another. Also, in future you will benefit greatly by keeping copies of these documents in a safe place. As your practice matures and you try to enter other insurance policies, you will have a wealth of readily available information.

Do not forget to check everything again after completing the application. Basically triple check and look at this to anyone else. Don’t expect carriers to fix an obvious mistake for you – it’s not their responsibility, and clearly they won’t. Double and triple checking may not be of much importance, as the whole process may take a month or more with minimal error.

Finally, after submitting your information, please allow sufficient time (1-2 weeks for emailed submissions) and contact the service desk of the provider to confirm the receipt. If you can get a contact name in your initial inquiry, call them directly. Once the receipt is confirmed, do not hesitate to reply again within 3-4 weeks whether they have already reviewed it or if they have found a problem. If everything is on schedule, consider returning in 3-4 weeks until the process is complete. If you can learn on the phone that there is some kind of delay, it can save a lot of time. As mentioned above, you expect this process to last several months – credential offices are often centralized and can review hundreds of submissions for many different areas at any given time. If there is no movement after several months, consider increasing your talk weekly.

Hopefully, your hard work and phone calls were paid and got you through the insurance reference process in just a few months with your original list of 7 or 8 carriers. If you want to take the challenge again, consider going back to your long list of 10-15 and start the process with the rest of the providers.

Some shortcuts

Here are some shortcuts to the above mentioned credentials.

Seek professional help: There are many different organizations that can help with the insurance login process. If you have concluded a contract with a practice manager, this process is often already covered. If you are considering a medical billing company to manage your insurance and patient billing, they should definitely have experience with the carrier to provide at least some guidance on not managing the process for you . There are also some professional insurance reference companies that specialize in this process for new products, but they can often come at a high price.

Universal Credential Data Source: The Council for Affordable Quality Healthcare has developed an online service that eliminates the need to file requests from multiple insurance companies. In short, you fill out a form for all of your participating insurers and you authorize who gets your data. The CAQH Universal Credential Data Source is located at:


The insurance certification process is critical to getting your practice off to a good start and ensuring a rapid transition to profitability. While this can be time consuming, an early start gives you a chance to address any issue. Be patient and keep these tips in mind and you will get through this:

Initial Start – Process is expected to take 6 months to complete

Choose a target list – don’t try for every courier out there

Check your work again before sending

Follow regularly and keep this process going

Don’t be overwhelmed – it’s just paper.

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