Do you want to help more patients and make your treatment better? Insurance paneling can help you a lot! More people can use your health care services when you join well-known insurance companies via insurance paneling.

Are you not sure what to do with the process of medical insurance paneling? Remember not to worry!
We’re here to help you all the way through.

Get to know the people who are giving out credentials i.e. the credentialing panel. It tells you what to do and what paperwork is needed to verify your skills. It will also help you meet the standards if you know the paneling rules for each insurance company.

Follow these simple steps to learn about insurance panels and help your practice grow. Let’s start!

Get paneled with any insurance company of your choice!

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Understanding Insurance Paneling In Healthcare

An insurance panel refers to the list of healthcare providers that a health insurance payer (e.g. insurance company) has contracted with to provide medical services to its members at pre-negotiated rates. Joining an insurance panel means that a healthcare provider, such as a therapist, psychologist, or counselor, has entered into an agreement with a health insurance company to become an in-network provider for that insurer.

As an in-network provider, the healthcare professional agrees to the insurer’s contracted rates for services rendered to the insurance company’s members. In return, the provider gains access to the insurer’s covered patient population, with the advantage that patients face lower out-of-pocket costs for services from in-network providers compared to out-of-network providers.

Important terms related to insurance panels include in-network providers, who are healthcare professionals that have joined an insurer’s panel, and out-of-network providers, who have not contracted with a particular insurance company. Health insurance payers create provider networks by credentialing and contracting with providers who meet their criteria.

In contrast, providers who remain out-of-network do not join insurance panels. Out-of-network providers can set their own rates and are not bound to the terms and conditions set by insurers. They provide services to patients covered by that insurance, but the patient must pay upfront and submit claims themselves to seek reimbursement from their insurer at the out-of-network rate. Here the provider does not get paid directly by the insurer.

Step-by-Step Process for Getting Paneled with Insurance Companies

When you get paneled with an insurance company, you agree to work with them as a provider for a certain health insurance plan. After this insurance paneling, patients with a certain health insurance plan can come to your practice for care, and you can bill their insurance company for it.

Do not forget! Remember! Insurance companies only prefer paneling those healthcare providers who can help them manage healthcare costs. They are always on the lookout for medical service providers who will take less money. In contrast, health care workers want to work with insurance companies that will pay them more for their services. So finding the perfect insurance company to get paneled with becomes challenging for a doctor, but not impossible.

Here is a step-by-step guide on how to get paneled with insurance companies as a healthcare provider:

Step 1: Getting Your Documents Ready

Before applying to get paneled with insurance companies, you will require a lot of information and documentation. It is crucial to arrange these documents to avoid any kind of delay and denial in your application approval.

The documents are:  

• Licensure information
• Practice address
• NPI number
• Resume
• Proof of malpractice insurance
• Taxonomy code (if you plan to bill Medicare/Medicaid)
• Proof of liability insurance from your landlord (if you rent)
• Advanced training or credentialing paperwork (if you have any)

Step 2: Searching For Different Insurance Companies

Now as you have arranged all these documents, it’s time to look for different insurance companies. Keep in mind that each insurance company has its own rules and payment rates. Even some of the companies require years of experience before they’ll sign insurance paneling agreements with you.

Therefore, before you look for an insurance company, here are some important things to keep in mind:

Network Size — Look for insurers with large coverage networks in your geographic area to gain access to more potential patients. Larger insurers like UnitedHealthcare, Aetna, and Blue Cross Blue Shield often have expansive networks.

Reimbursement Rates — You should compare the rates that different insurers offer for the typical procedures you do. Higher rates mean more revenue per patient visit. Get the fee plans from each insurance company to help you decide which one to go with.

Experience Requirements — Some insurers require 1-2 years of practice experience before they will accept you as a provider. Therefore, when choosing an insurance company, you should look at these requirements and pick one without strict experience requirements.

Credentialing Timeline — Keep in mind that provider insurance paneling process could take 3 to 6 months. Therefore, we advise you to pick plans like Cigna and Humana that can get you credentialed faster so you can start sooner.

Payment Reliability — Make sure that insurance companies pay claims on time. You can find out about this by reading online reviews and asking coworkers about their own experiences. This step is very important because it will help you make steady money, which is important for any healthcare business.

Plan Types — Determine which types of plans are dominant in your area – PPOs, HMOs, EPOs, etc. After that, focus on insurance companies that offer those specific plans to get in touch with more patients in your target area.

Value-Based Care Initiatives — Check with each insurance company to see what role they play in value-based care models, such as responsible care organizations (ACOs) or patient-centered medical homes (PCMHs). These programs can change how care is given and how much is paid for it.

Administrative Support — Last but not least, look for insurance companies that offer helpful tools like online portals, electronic claims filing, and specific reps for providers. This help could make it a lot easier for your team in the administrative process.

In addition, applying to 3-5 insurance companies that align with your geographic location, specialties, experience level, and business needs can position your practice for success as an in-network provider.

Step 3: Submitting The Credentialing Application

Health care workers must send a separate application to each health insurance company they wish to work with in order to begin the provider credentialing and paneling process.

Now, here’s a handy tip: many insurance companies use the Council for Affordable Quality Healthcare (CAQH) for provider insurance paneling. The streamlined application system created by CAQH is called CAQH ProView, and it really helps providers get their credentials more quickly.

Once you’ve sent your application via CAQH, the insurance company you’re targeting will provide you with a unique application number. This number is quite useful because it allows you to see where your application stands in the credentialing process and helps you keep track of everything.

The CAQH ProView application serves as a centralized repository for your professional and practice information. This means you won’t have to submit separate applications to multiple insurance companies, which is a real time-saver. This feature reduces administrative burden and ensures consistency in the information you provide to payers.

Now, it’s very important to get the entry form right. Make sure to include all the necessary documents, such as your professional license, certifications, malpractice insurance, and details about your business. Paying close attention to every detail when you apply will help speed up the process.

Step 4: Following Up After Application

Once you send your insurance paneling application to the health insurance company, you should check back soon. Most insurance companies will give you an idea of how long it will take to get your credentials, which is generally between 4 and 6 weeks. Check in with the provider relations group again in 4 weeks to see how your application is going.

Make sure you have your NPI number, Tax ID number, and application reference number with you when you follow up. Make sure they got your complete application. This includes everything that is attached, like licenses, certificates, liability insurance, and a DEA certificate. Make sure that no more information is needed to finish the process of getting credentialed as an in-network provider.

If the application is still being worked on, follow up again in 6 weeks. Always following up in a professional way lets them know that you want to be a part of their network.

If your application is turned down, request the reasons in writing. Not having enough malpractice insurance or not being eligible for Medicare are some common reasons for rejection. Fix any issues and try again.

In your subsequent application, mention improvements like extended hours, bilingual staff, EMR systems, or new services offered. Joining provider panels can take persistence through multiple application cycles.

You can finish the process quickly if you keep checking on your credentialing application. Checking status routinely demonstrates your commitment to the insurer’s network and patients.

Step 5: Reviewing The Terms of Approval

Once insurance companies agree to let you join their network of providers, it’s important to read the terms and conditions carefully before signing any contracts. This will help keep problems from happening in the future.

Key things to look over:

Reimbursement Rates — Look over the fee schedules for your specialty to make sure the rates of reimbursement are fair. Keep a close eye on the relative value units (RVUs) that go with the CPT codes you bill most often.

Billing and Coding — Make sure you can meet all the standards for billing and coding. You should know what variations, CPT codes, and ICD diagnostic codes are accepted. Also, look over how to submit claims, when they need to be sent, and whether electronic or paper claims should be used.

Authorization Requirements — Write down any permissions, referrals, or other paperwork that you need to get before you can perform certain medical services or procedures.

Contract Exclusions — Look out for exclusions for medical services, procedures, diagnoses, or types of providers that you might want to offer.

Appeals Process — Understand the process and timeframes for claim appeals and denials.

Penalties — Carefully review any fines, fees that need to be paid back, or other punishments for not following medical billing rules or other terms.

Provider Portal Access — Make sure you can get to the portals that let you check on things like a patient’s eligibility, the state of their claims, the authorization requirements, and more.

Checking the contract terms carefully before signing will help you avoid problems and make sure the process goes smoothly with the payer. Use the network contract checklist and also have a lawyer look it over.

Some Important Tips

Here are some important things to keep in mind that could make it easy for you to get on the insurance companies’ lists and keep you out of trouble.

Get Board Certification

Getting board certification is an important step you don’t want to skip if you want to be accepted by big health insurance companies. This license is very important because it shows that you’ve been trained and tested very carefully in your field. It’s all about showing that you meet the high standards of ethics and practice that insurers want to see.

Most big insurance companies need this license to make sure that the doctors in their network are providing good care. So, when you’re done with your residency, you can choose to take an exam in your field, whether it’s internal medicine, pediatrics, or something else. Passing that test shows that you know what you’re talking about and are dedicated to keeping updated in your field.

Certain smaller insurers might not need board qualification right away, but having it makes you much more competitive. It’s a great way to show that you are committed to giving excellent care that is based on convincing evidence. So, you should definitely think about it!

Consider Intern Policy

When working with insurance companies as a healthcare provider, it is important to carefully consider your intern policies. Unlicensed interns, even if they have finished their degrees, are often not credentialed to bill for services on their own. In some states, Medicare and Medicaid let billing happen under a supervisor. But in other situations, this might be considered insurance fraud. To prevent problems, look up the laws in your state and understand the insurance policies for interns from each insurance company. If you check the rules carefully at the start, you can feel sure about making internship opportunities that follow billing regulations.

Know The Required Time

When you apply to work with insurance companies, it is important to know how long they take to review and approve your application. Every carrier has its own rules about how long the vetting process will take. Check how long it usually takes to get things done. This will help you know what to expect. Knowing the needed time helps you check in at the right times. During the paneling process, there are often many requests back and forth. It is important to keep track of response times to avoid delays on your side. Following the insurer’s schedule shows your professionalism and dedication to building the partnership.

Remember Previous Disciplinary Action (if any)

When you apply to get paneled with insurance companies, it is very important to be honest about any past disciplinary actions against you. Having a record of discipline does not mean you will be disqualified. However, if you do not tell about it, it can hurt your trustworthiness and slow down the approval process. Insurance companies will check your background very carefully, so being honest is always the best choice. Explain what happened with the discipline and highlight the good actions you have taken since that time. Showing that you have grown and take responsibility can help reduce worries. If you are honest and clear, you can still be accepted even if you had a past issue.

Know If You Are A New Licensee

Some insurance payers like to choose providers who have many years of experience before bringing them on board. As a new licensee, find insurance companies that accept new practitioners. You might also think about starting with Medicaid or Medicare if your state permits new providers. Build up your patient roster and get that initial experience. In one or two years, you will be better able to meet stricter requirements from commercial insurers. Do your homework first. This way, you won’t waste time applying to panels that will not accept you.

Stay Informed

For healthcare workers, getting on the panels of insurance companies is a big deal, but it’s only the start. Learn the most recent rules and guidelines from these insurance groups. This is the most important thing you can do to keep a friendship going on with them.

Insurance firms are very active and often change their rules to keep costs low and help people get good care. Stay alert and watch for these changes. It will be simple to make your business fit what they want. Through trust and following through, this builds a strong connection that lasts. It also makes sure that you can keep your services running. Be ready to learn something new all the time. Read insurance company papers, go to their seminars, and communicate with the relevant people in your field every day.

Benefits Of Getting Paneled With Insurance Companies

Getting paneled with insurance companies brings many benefits to healthcare providers. The most notable of them is that it opens windows to new opportunities, and assists you to grow footfalls of patients to your practice.

It Gets You More Patients.

When you join a lot of different insurance networks, you can get more patients who can use their plans to find your healthcare office and get care services.

It Boosts Your Chances Of Making Money.

More people will be able to get medical care from you if you are on the panels of more insurance companies. With this, you may be able to potentially make more money.

It Makes It Easier For People To Get Multiple Care Services.

You can make it easier for people to get a variety of low-cost medical services. People who really need care but can’t pay for it will benefit from this.

It Improves Your Professional Image.

One way to boost your credibility as an insurance agent is to be in network with respectable firms. This proves that your schooling, experience, and license are at the very best level required by these insurance companies.

Still Doing Credentialing Yourself? Stop the Madness!

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Our medical credentialing service empower you to see patients months sooner than doing it yourself.

No more staying late or working weekends on credentialing. Outsource to us and take back your evenings and weekends!

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Assisting with billing, credentialing and enrollment, BellMedEx has been consistently reliable from the first day of our relationship.

Dr. Mike

Internal Specialist Medicine

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One in seven medical claims are denied, leading to approximately 200 million rejections daily. Of these, a significant 27% are due to issues with patient registration and Verify Medicare Coverage thing for the medical claim.

On average, denial management costs at least $25 per claim denial, resulting in cash flow issues for healthcare practices’ Revenue Cycle Management (RCM).

When the Verify Medicare Coverage part is not done correctly, it not only drives up billing costs but also delays revenue collection, causing disruptions throughout the revenue cycle.

Implementing a reliable insurance verification process helps mitigate claim denials, streamlining medical billing and ultimately improving the practice’s financial health.

This document offers a detailed guide on how to Verify Medicare Coverage, eligibility, and benefits for providers using various methods.

What is Medicare Coverage Verification for Providers?

Medicare coverage verification is the process of checking that a healthcare service or item will be paid for by Medicare before it is provided.

Medicare is a federal health insurance program that covers certain medical costs for people aged 65 and over. While Medicare pays for things like doctor visits, hospital stays, lab tests, and prescriptions, it does not cover all health expenses. Medicare coverage verification allows healthcare providers and patients to confirm in advance that a proposed treatment or service will be covered and reimbursed by Medicare.

For example, before scheduling an MRI, a doctor’s office may contact Medicare to verify that the scan will be covered for that patient. This prevents unexpected costs and ensures the patient and provider are aware of any potential out-of-pocket expenses ahead of time.

“Medicare coverage verification refers to checking in advance whether something will be covered under Medicare for a particular patient. This prevents the patient or healthcare provider from assuming something is covered, only to find out later that Medicare denied the claim.”

Wyatt Butler, Medical Biller & RCM Expert

Why Do Providers Need to Verify Medicare Coverage?

Medicare Coverage Verification is essential for providers as it optimizes the revenue cycle and streamlines the collection process.

According to CompuGroup Medical, manual verification causes providers to lose the average visit cost of two patients per day, which amounts to $6000 annually. Therefore, staying electronic with verification saves you time, money, and effort.

Healthcare providers must verify their patient’s Medicare eligibility coverage due to the following reasons:

➜ Upfront eligibility verification improves your first-pass rate while reducing A/R days, meaning you’ll get paid faster without any delays.

➜ Checking Medicare eligibility before providing services gives you a better understanding of your patients’ co-pay amounts, co-insurance, deductibles, and out-of-pocket costs, allowing you to collect Medicare payments in a timely manner.

➜ Prior eligibility verification allows you to educate your patients ahead of time about the billing process with their insurance plan, co-pays, and deductibles. This leads to enhanced patient satisfaction and fewer contested bills.

➜ Lastly, it improves cash flow, as you collect your revenue upfront without any delays.

List of Things You Need to Verify Medicare Coverage of a Patient

• National Provider Identifier (NPI)
• Provider Transaction Access Number (PTAN)
• Tax Identification Number (TIN)
• Beneficiary Medicare ID
• Beneficiary name
• Beneficiary date of birth
• Date of service (if applicable)

How to Check Your Patient’s Medicare Eligibility Status?

Checking your patient’s Medicare eligibility is key to avoiding billing problems and getting paid on time. There are different ways to verify Medicare coverage, from online tools to phone calls. Here are the most common methods to help you confirm your patient’s Medicare eligibility.

Method #1 – BellMedEx Medicare Coverage Verification Tool

BellMedEx is a medical billing company that has its own comprehensive Medicare verification system. The company takes over a provider’s non-clinical burdens and simplifies the Medicare coverage verification process. This enables providers to focus on their core tasks, such as delivering care.

To verify Medicare insurance eligibility via BellMedEx, follow these simple steps: 

1). Visit BellMedEx’s Medicare Coverage & Patient Eligibility Checker Tool online.

2). Fill in the form – enter your name, email, and phone number – and click on “Book a Free Consultation”.

3). BellMedEx’s support representative will immediately contact you and help you with confirming your patient’s Medicare coverage.

4). Likewise, you can also contact BellMedEx at 888-987-6250 to receive Medicare coverage verification support and verify if a patient qualifies for Medicare or not.

Method #2 – Confirm Medicare Coverage Online via Secure Provider Online Tool (SPOT)

SPOT, as known as Secure Provider Online Tool, gives you the ability to view claims status and confirm patient’s Medicare eligibility status online. SPOT also offers the opportunity to search for a Medicare Beneficiary Identifier (MBI) through the Medicare MBI lookup tool.

The eligibility information through SPOT is accessible 24/7, and the providers can check Part A and Part B eligibility status, as well benefit eligibility for preventive services, deductibles, therapy caps, inpatient care, hospice, home health, Medicare secondary payer (MSP), plan coverage data categories, and claim status up to twelve months from the date of the inquiry.

Here’s how you can verify Medicare eligibility for your patients via SPOT:

1). Select Eligibility from the top drop down menu.

2). A pop up will appear, asking for the following details:

• Beneficiary Last Name
• Medicare Beneficiary ID
• Beneficiary First Name 
• Beneficiary Date of Birth
• Date(s) of Service

Note: (You may limit your query to the date(s) the service will be furnished to the patient, or you may specify any time up to four months in the future and 24 months in the past).

3). Click Search to view Eligibility status.

4). The Eligibility results will include complete eligibility information of the beneficiary, including part A and part B eligibility statuses, with effective and termination dates.

Method #3 – Using IVR to Verify Medicare Part A and Part B Eligibility

The Interactive Voice Response (IVR) system allows a provider to verify Medicare eligibility for free by phone. You can access primary insurance info, confirm pre-authorization, and check claim status.

Contact the following numbers for Medicare Part A verification:

• 1-888-664-4112 (Toll-free telephone number)
• 1-877-660-1759 (For speech and hearing impaired)

Contact the following numbers for Medicare Part B verification:

• 1-866-454-9007 (Toll-free telephone number)
• 1-877-660-1759 (speech and hearing impaired)

Providers can access Medicare Part A and Part B eligibility information via IVR during the following times (excluding holidays):

• Monday-Friday 7am to 7pm, ET
• Saturday 6am to 3pm, ET

IVR’s CSR service is also available in case a complexity arises about insurance plans, coverage, and benefits that you need to navigate through. Customer service representatives are available during the following times, excluding holiday closings:

• 8am to 4pm Monday through Friday, ET and CT for providers in Florida.
• 8am to 4pm Monday through Friday, ET for providers in the U.S. Virgin Islands.

Method #4 – Confirming Medicare Benefits via MAC Online Provider Portal

Medicare Administrative Contractors (MACs) process claims and Medicare eligibility verification for fee-for-service (FFS). These contractors offer an online provider portal for registered providers.

Not registered with MAC?

A supplier can register with its MAC’s provider portal by contacting its MAC or by finding its MAC provider portal online. Once registered, the supplier can use the portal to search a Medicare beneficiary’s eligibility. The supplier can access its MAC’s provider portal at any time and look up a beneficiary’s verification.

Here’s how you can verify Medicare coverage of your patient with MAC provider portal:

1. Enter the beneficiary’s Health Insurance Claim Number (HICN) or Medicare Beneficiary Identifier (MBI)
2. Beneficiary’s first and last name
3. Beneficiary’s date of birth
4. Upon entering the above information you can check the status.

However, the process is self-service, meaning you are responsible for entering the information to check the status.

Method #5 – Phone Number to Verify Medicare Eligibility and Benefits

Using Medicare Administrative Contractor (MAC) Phone Verification

Medicare Administrative Contractors offer a phone verification system as well that Medicare suppliers can contact to access beneficiary eligibility information. The appropriate phone number of a MAC can be found from its website by state. Or you can simply dial 1-800-MEDICARE (800-633-4227) to get your state’s phone number.

To perform the eligibility verification, the authentication should be done through the phone system by entering:

• National Provider Identifier (NPI), 
• Provider Transaction Access Number (PTAN), and 
• Tax Identification Number 

This information is needed by Medicare to accurately perform the eligibility query and provider authentication. Once the provider has confirmed its authentication, the provider can now enter the following details to confirm the patient’s Medicare eligibility.

• The beneficiary’s HICN or MBI, 
• The beneficiary’s first and last name, and 
• The beneficiary’s date of birth 

This option is self-service and available around the clock, 24/7.

Method #6 – Validate Medicare Coverage via HIPAA Eligibility Transaction System (HETS)

HETS (HIPAA Eligibility Transaction System) allows providers and suppliers to verify and check Medicare eligibility status using a HIPAA compliant transaction. You can get eligibility information by submitting a HETS 270 request. To check eligibility status in HETS, you must have the following information:

• MBI
• First and last name
• Date of birth (MM/DD/YYYY)

If a patient is eligible, you will get a 271 response with information like Part A entitlement, Part B entitlement, Part D, Hospital lifetime reserve days remaining, skilled nursing facility remaining benefit days, and more.

Note: To verify your patients’ Medicare eligibility via Health Eligibility Transaction System, your medical billing software must connect with it. This integration permits creating, sending, and getting the transactions. HETS benefits large healthcare facilities with the resources to build their own programs. This makes it a good choice if you want to avoid third parties and keep things quick and secure.

Conclusion

Now that you know how to verify Medicare eligibility and verify Medicare benefits across multiple methods—whether through IVR, MACs, or online platforms like SPOT—you can streamline your verification process. This will help reduce denials, improve patient billing accuracy, and increase your cash flow. Efficient Medicare verification for providers is key to ensuring your practice operates smoothly, so make sure to verify Medicare eligibility as soon as possible to avoid delays in claims processing.