The process of ”accreditation” or ”supplier registration” with an insurance network actually consists of two phases. 1) Certification and 2) Conclusion of the contract. The registration phase is when the insurance company verifies all of your credentials and you meet their requirements to participate in their network. During the contractual phase, the Company will issue you an agreement through a participating provider setting out the terms and conditions to receive reimbursement of your claims on the network. 1. Do amendments to the contract have to be signed by both parties? Often, health plans attempt to limit their administrative burden by changing their agreements with providers without the prior written consent of the physician. You should have the opportunity to carefully review any changes to the contract in advance, and the signature of both parties for the changes is highly recommended. If this is a capitulation in primary care, will the health care system provide you with detailed information about the specific services that fall under capitation? The plan should be able to do this, which will help you determine if capitation is appropriate. Does your firm offer unique services that benefit the health care plan and its members? For example, is your practice accredited by a clinical quality organization? Or do you have outcome studies or quality or medical management data from other risky contracts that can add value to the health care plan? Accreditation is a process that insurance companies use to review your education, training, and work experience and ensure that you meet their internal requirements to serve as a networked provider in their panel.
Insurance companies are required to provide web-based provider directories listing all networked providers for their plans. These online directories are regularly used by health service consumers to find doctors and other health care providers who accept their insurance. The first step in implementing your new revenue cycle is to enroll and enroll in insurance plans that are important to your service area. At the end of the transaction, consumers can find you as a participating supplier in their panel for their specific area of expertise. All health insurance companies and networks will indicate that you need to purchase malpractice insurance and request a copy of your malpractice insurance statement page. Make sure your limits match or exceed the amount stated in the insurance network contract and have a copy of the declaration page ready for the application process. Healthcare providers venturing into private practice often don`t know how to define their procedures for billing for services through third-party networks. The billing and reimbursement process is called the ”revenue cycle.” The first step in the revenue cycle is to obtain credentials and a contract with a participating provider with insurance companies that are important to your service area.
Building a successful revenue cycle for a new practice can be a complicated matter, but with a little planning, you can make the process a little less intimidating. Let`s go over a few important steps in the process to give you a guide on how to set up the revenue cycle for your new practice. As a healthcare provider, your time and energy should be primarily focused on patient outcomes. However, dealing with payers can be tedious and time-consuming. Preparing to renegotiate multiple supplier contracts can simply make you too thin. Most of the time, you will work for a company or start your own practice. Some chiropractors may work as sole proprietors under their own Social Security number. Make sure you know how you will charge for your services and clarify the structure with your employer or accountant and/or lawyer if you are an independent contractor or firm owner. The time to find out is not after certification. Any changes to the tax number or billing structure require you to log in again and start the entire process all over again.
When a doctor is asked about negotiating contracts with insurance companies, a typical reaction may be a dip in the shoulder, often accompanied by a depressive sigh. Once you`ve mastered the components of the contract, it`s time to collect internal data. Since most providers are contractually associated with multiple payers, check your top 5 or 10 payers first. Identify your most frequently billed services and compare the payment amounts you receive from each of your major payers. With this data, you can analyze the financial performance of each supplier contract. Then you can set target goals for negotiation. Does the health care system introduce employer-specific head quotas? Various types of contracts that exist under direct contracts, service fees, risk-based (using capitation or other global payment methods), service level agreements and, in some cases, medical tourism. A popular example of direct contracts is Walmart`s deal with the Cleveland Clinic for Cardiac Surgery.
The retailer also works with Johns Hopkins Hospital in Baltimore for joint replacement surgery and the mayo clinic for transplants and cancer treatment. Before starting negotiations with a health plan, identify all the levers you can use in the contracting process. This task is easier said than done, and timing can play an important role. Now that you are a participating provider, you can start charging the health plan for your services. Invoicing is another area of the revenue cycle that is often better for outsourcing than for in-house outsourcing. .