If you’re considering accepting health insurance at your private practice, then you’ve probably come across the term credentialing. The credentialing process allows clinicians to become in-network providers with insurance companies, meaning that their services can often be covered by patient insurance plans. While the process may seem complex, understanding and approaching each step individually makes it more manageable. 

In this guide, we outline the credentialing process and help you navigate becoming an in-network provider. 

Why is insurance credentialing important for your private practice?

Insurance credentialing, also known as paneling, is the process of getting approved to accept insurance from specific insurance providers. Many private practice clinicians decide to get credentialed in order to increase accessibility for their services, attract more clients, and therefore create a steady revenue stream. 

Many clients only seek clinicians who are in-network with their insurance to make services more affordable.Costs for out-of-network clinicians can be significantly higher and pose a real barrier to seeking recurrent, longitudinal care. 

In addition to making your services more accessible, credentialing can also enhance the credibility of your practice. Being in-network signals that an insurance company has vetted and verified your qualifications, education, and work history to confirm that you meet their standards for providing care. 

Understanding the credentialing process for private practice 

The credentialing process for private practice can take several months depending on the specific insurance company and required documentation. We can break this process down into 6 steps:

1. Research and select insurance payers to enroll with
2. Create a Council for Affordable Quality Healthcare (CAQH) Profile
3. Submit credentialing applications (and follow-up!)
4. Undergo insurance panel committee review
5. Review proposed fee schedules
6. Receive approval and sign contracts

{{free-trial-signup}}

Selecting and applying to insurance providers

While it may seem beneficial to apply for all insurance providers to maximize your client base, this approach can be resource-intensive and inefficient. Since credentialing must be completed separately to join each payer panel, it’s more effective to focus on payers that best align with your practice and the insurance plans most commonly used by your target clients. 

Additionally, payers may not be open for enrollment consistently, so knowing which payers are actively enrolling providers with your specialty will be helpful in getting your credentialing process started – this you can learn by calling the payer and asking directly. 

Finding the best fit with insurance providers 

When evaluating insurance providers, you will want to consider which insurers are most commonly used by your potential clients. You can search for this information a few ways:

1. Check State and Regional Insurance Market Data: Many states provide reports on the most common health insurance plans in the area. You can check your state’s Department of Insurance website or look at CMS (Centers for Medicare & Medicaid Services) reports. 

2. Use Provider Directories: Major insurers like Blue Cross Blue Shield, Aetna, UnitedHealthcare, and Cigna offer provider directories where you can search for providers in your area. If a particular insurer dominates the list, it’s a good sign that many residents have that plan. 

3. Ask Clients, Peers, and Local Employers: Sending a survey to existing clients, discussing informally with your professional network, or speaking to the HR department of local businesses can help you gather some understanding of which insurance providers are common in your local area. 

Submit your credentialing applications to insurance providers

Once you’ve identified the insurance payers you’d like to work with, the next step is submitting applications. Most insurers have online portals where you can access and complete the credentialing application. This process typically involves providing:

• Business Information: Your practice’s name, tax identification number, National Provider Identifier (NPI) and business address. Tip – if you have more than one NPI number (ie. an NPI Type 1 for you specifically and an NPI Type 2 for your practice, consider which NPI number you’d like to use for your credentialing application. More on NPI Types here. 
• Professional Credentials: Your education, licensure, certifications, and malpractice insurance details. Yes, you’ll need to have professional liability insurance in place – but don’t worry, that is generally low cost and easy to obtain. 
• Practice Information: The types of services you provide, client demographics, and whether you offer in-person, telehealth, or a hybrid care model. 

Most insurers will then pull your credentialing information from CAQH. If you already have a profile, ensure it is up-to-date and that you have authorized the insurer to access it. If you have yet to create your CAQH profile, move on to the next step. 

Creating a Council for Affordable Quality Healthcare (CAQH) Profile 

The CAQH application is widely used by insurance clinicians for credentialing. This profile serves as a centralized database where insurers can verify your credentials.

Who needs to create a CAQH profile and when? 

Any clinician seeking insurance panel credentialing with major insurers should create a CAQH profile. This step is typically required after submitting an insurance credentialing application, as most insurers will not begin processing without CAQH enrollment.

For detailed guidance, check out our blog on CAQH applications: Tips for Filling Out the CAQH Application

What's next: following up and responding to insurer inquiries

After submitting your insurance credentialing application and creating a CAQH profile, it’s best practice to follow up with insurance companies to ensure your application remains in good standing. Insurers may request additional information during the credentialing process, and periodic follow ups help prevent missed requests that could delay approval. 

Be proactive in checking emails and responding promptly to any queries. If an insurer requests corrections or additional documentation, submit the necessary updates as soon as possible and follow-up directly to confirm your application is back on track.  

Credentialing reviews and offers

Once your application has been processed, the insurer will review your qualifications, confirm your compliance with state and federal regulations, and determine if your practice aligns with their network needs. The review phase typically involves two key steps before moving ahead to the contract offer: undergoing an internal insurance panel committee review and reviewing the proposed fee scheduling. 

Insurance panel committee review

After document verification, an internal insurance panel will review the application to determine approval. This step ensures that clinicians meet network requirements and compliance standards. This part of the process is done internally by the insurer and typically does not require any participation from the clinician. 

Review the proposed fee schedule

Once deemed a fit for their network, insurers will provide a fee schedule outlining reimbursement rates for services. Review these carefully to ensure they align with your financial expectations. A therapist specializing in cognitive behavioral therapy, for instance, should compare reimbursement rates for CPT codes like 90834 (45-minute therapy session) across different insurers. In some cases, these reimbursement rates are negotiable, which might be necessary as they can be a key factor in calculating your session rates to ensure your practice is set up for financial success. If the initial rate seems too low, you can attempt negotiating by presenting data on your experience, specialization, client demand, and regional market rates to justify a higher reimbursement amount. 

Fee schedules are not made public, apart from CMS. If you did not receive the fee schedule from your payer during the application approval process, connect with the provider coordinator to ensure you receive it.

Credentialing approval and contract offer

Once the application is approved, the insurer will send a contract outlining the terms of your in-network participation, including the aforementioned reimbursement rates, and clinician obligations. Carefully review this contract to ensure you fully understand the expectations. If you’re unsure, you can request clarification or seek legal guidance if needed. 

Becoming in-network is official only after you sign and return the contract, and the insurer processes it. Ensure that you have a copy of the fully executed contract to keep for your records. Once finalized, you’ll receive confirmation of your network status, allowing you to start billing the insurance company for services. It’s a good idea to verify your listing in the insurer’s provider directory to ensure potential clients can find you. 

How much does insurance credentialing cost? 

Fees vary based from insurer to insurer, and this information will usually be included with the application requirements. Some clinicians decide to enlist insurance credentialing services to assist with applications. These services while third-party credentialing services may charge between $500 and $2,000. 

What to do if your credentialing application is not approved

Denials can happen for several reasons, such as network saturation, missing documentation, or failure to meet specific qualifications. If your application is denied, you can:

• Request an Explanation: Contact the insurer to understand the reason for the denial. Some insurers provide specific feedback, while others may allow resubmission after a certain period. 
• Appeal the Decision: If the insurer allows appeals, prepare a response addressing their concerns. Provide additional documentation or clarify discrepancies. 
• Consider Other Insurers: If a particular insurer is not an option at this time, revisit alternatives that may be a better fit for your practice. 
• Reapply Later: Some insurance networks have open and closed enrollment periods for credentialing. If denied due to network saturation, you may be able to reapply when the new enrollment period begins. 

Healthie is an insurance billing platform built for private practice 

The credentialing process for private practice can be time-intensive, but also a big step for clinicians looking to expand their patient base and ensure steady reimbursement. Healthie, an all-in-one EHR, patient engagement, and practice management platform designed for private practices, offers integrated insurance billing features that reduce administrative tasks for clinicians. By automating claim submissions and tracking, Healthie helps providers improve efficiency, minimize errors, and increase the likelihood of successful and timely insurance reimbursements.