Posted by admin | Posted in Credentialing, Physician Credentialing, Provider Enrollment | Posted on 23-12-2010
Why join insurance panels and go through all the provider enrollment work and effort? For many if not most practices it’s a matter of absolute economic necessity. It’s been estimated that nearly 85% of US citizens are covered by some sort of health care insurance. This can be through their employer or the employer of their spouse or parent, purchased individually or provided by one government program or another. It goes without saying that if you’re going to attract clients to your practice or facility, you will need to get credentialed with the principal commercial health insurers in your area as well as Medicare and the state sponsored Medicaid program. If a practice doesn’t joined these panels, the vast majority of those seeking care will end up seeking it with those providers who do accept their insurance programs.
A second important reason for joining insurance panels is that more and more people are joining and will be joining the ranks of the insured. The most significant driver of this phenomenon is the new healthcare law. While the final framework of the bill is still in doubt, it’s important that you seriously consider those provisions that will likely have a major impact on the patient flows. Current estimates have it that 45 million people here in the US are currently uninsured. The new law provides a opportunity for the majority of them to purchase health insurance through an “exchange” system. These exchanges/ cooperatives, while established and regulated by state governments, will be composed of commercial insurance entities. To enable you to tap into this influx of new clients, you’ll need to be credentialed with those firms participating in the exchange. Another feature of the new health care law that will increase the ranks of the insured is the elimination of the current “preexisting condition” restriction. I think it’s fair to say, because of it’s overwhelming popularity, that regardless of the what the final health care law looks like, this provision will remain in effect. So even if, in it’s final configuration, the health care reform restricts the number of uninsured people added to the rolls of the insured, this provision alone will prevent insurance companies from reducing the number of people currently covered, thereby maintaining current coverage levels.
There are two other broad industry related trends that will increase the need for broad insurance provider enrollment. The first is mental health parity where metal health problems are given the same insurance coverage consideration as biologically related ones. This means, of course, that more people will be seeking help for conditions they didn’t in the past. The second is a recent trend for individuals to select HMO’s over PPO’s. This is a tendency that historically appears during difficult economic times. The net effect of this shift is a reduction in out-of-network benefits which in turn means that a client will think twice before going to a provider not a member of of his or her HMO.
All of these trends make it clear that getting credentialed with the key insurance payors in your market is extremely important to the success of your or your clients practice. And although the provider enrollment process can be a long and difficult one, for most practices it is a necessity.