Provider Credentialing: What if the Insurance Is Closed?

Those inexperienced in the credentialing process world might be surprised to learn that insurance companies can close their panels and refuse to accept new providers. As surprising as this situation might sound, insurance company decision-makers can and do inform prospective applicants that they are not accepting new providers — and those being turned away are most often specialists in the areas of physical therapy, podiatry, radiology, and cardiology.

This situation has left many providers wondering whether anything can be done. Luckily, there are a few opportunities. First, providers need to become informed. According to New York state regulations, insurance company employees are obligated to maintain thriving networks and meet regulations. The Department of Health uses the following standards to determine network adequacy:

• The network must include at least one hospital in each county; however, for Erie, Monroe, Nassau, Suffolk, Westchester, Bronx, Kings, New York, and Queens, the network will need to include at least three hospitals.
• The network must offer a choice of three primary care physicians (PCPs) in each county and potentially more based on enrollment and geographic accessibility.
• The network must include at least two of each specialist provider type and potentially more based on enrollment and geographic accessibility.

With this information in hand, providers are better equipped to fight insurance company leaders’ rejections. Providers have the right to appeal their network denials to participate by adequately evaluating the previously stated regulations. Support of local politicians also seems to help in some cases.

Part of a successful appeal includes proving that you offer unique services at your practice. For example, this can include dental practices that offer post-procedure recovery, rather than having a patient go to a hospital. This service is looked upon as a win for insurance company leaders because it reduces their costs. Another option is to join an independent practice association network that can provide enrollment into closed panels but will charge a percentage of gross revenue received from that plan.

WCH professionals have been providing credentialing services for more than 15 years. From experience, we can say that there is no one solution for this issue. It’s a matter of fighting for your spot in the network and marketing your professional skills the best way you can. Know that there are options available to get into closed panels, and WCH can help you evaluate those options and develop a plan to successfully gain access to a closed insurance panel.

[cta]For more information about how WCH Service Bureau experts can help the professionals in your office, contact us or give us a call at (718) 934-6714.[/cta]