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Rookie question re: credentialing with payors

  • 1.  Rookie question re: credentialing with payors

    Posted 05-22-2018 12:33
    Dear All,

    I am credentialed with all the major payors in my state but am breaking away from a large employer to start my own solo practice in the coming months. The rep at Aetna said I just need to send them a new w-9 with my ein and all will be well. This seems too easy and the rep did not inspire much confidence. Do I need to create new contracts between the payors and my sole proprietor LLC?

    Thank you

    Elizabeth Bird, MD
    Chester CT

  • 2.  RE: Rookie question re: credentialing with payors

    Posted 05-23-2018 05:44
    Hi Elizabeth
    Aetna is a full service ehr/pm/billing/medical reception company that will do your admin, billing, credentialling and even handle all of your faxes for you and then send u a paycheck every month. They can apply to every insurance company they want you want to contract with- they use your info from your cahq profile and your tax id, corporate filing documents and your bank account. This sounds great because it is an incredible amount of work to get everything set up by yourself, find an electronic health record system you like and get it configured and installed snd train everyone to use it, find a clearinghouse to send your bills through and set up all of your payors and accoubts, and then learn how to code and bill for your work while trying to care for your patients. Also, as an independent, the insurance companies are not exactly in a rush to sign you up so they can take from 90 days to 180 days to even respond to your application.  In my experience in ohio it takes an average of 90 days after they accept you to send you a signed contract which means you are out of network for 6 to 9 months. A lot of companies are closed to new providers as well - especially in primary care. Aetna is huge do they have a lit more clout and can take care of that much more quickly than you can on your own.
    but you are absolutely right to be thinking there is a catch if you choose aetna.  If you sign with aetna consider yourself an employee. They tell you how many patients to see every day and how much time you have for a visit. They own all of your information, have all of your administration documents and control all of your money.  Basically you pay for your own space, equip, workers, etc. but they taking anywhere from 20% or more of your income. If you dont meet their monthly minimum they take a lot more than 20%. Who knows for sure what you are being charged since they have the contracts so you dont even know what rates you have agreed to with the insurance companies. All mony goes through them snd they do all accounting. Also, they tell you who to refer to, which lab company to use, which tests to order, which protocols to use, how to conduct your visits for each confition etc so  you give away a great deal of professional autonomy.  But on the other hand it saves a great deal of work and a very steep learning curve figuring out how to do it all yourself. I have often wondered if iwould have been better off taking that path.  I guess i am too wary of giving that much power over to an entity i barely know.

    Michelle Meyer

  • 3.  RE: Rookie question re: credentialing with payors

    Posted 05-23-2018 07:07
    I would expect that once you do this, they will send you a standard contract and then you will have to negotiate from there.  The larger group may have had better terms but it is unlikely that they would carry that over to your new sole proprietorship, so the rep is likely just wanting to reset things back to the standard terms and that explains the cursory attitude.

    There is no such thing as failure. Only the distance you are willing to travel in pursuit of a dream.
    Gregory Sharp
    Ideal Family Healthcare
    Manitou Springs CO

  • 4.  RE: Rookie question re: credentialing with payors

    Posted 05-23-2018 07:48
    I think you need a new contract.  My fear would be that you start seeing patients and they continue to pay your old employer.  If that happens it can be a pain to fix.

    Michael Barron MD 

  • 5.  RE: Rookie question re: credentialing with payors

    Posted 05-23-2018 08:50
    I started my practice a couple of years ago and had to redo all the contracts. You will need a new billing NPI, TIN and W-9. It took about 3 months or longer to get credentialed. Blue cross was the quickest.

    Justin Heath, DO
    Heath Family Medical
    Fallon NV

  • 6.  RE: Rookie question re: credentialing with payors

    Posted 05-23-2018 14:52
    With most insurances I went through a local PHO, and a few contracts I have independently.  The PHO generally can get contracts with insurances were not interested in single providers  and higher rates of payment however there is also more reporting involved with this.
    let  me know if you need more information.  I started my practice about 4 years ago.
    Best of luck

    naomi rosenberg
    primary care medicine and pediatrics, llc
    Westfield MA
    413 562-1650

  • 7.  RE: Rookie question re: credentialing with payors

    Posted 05-23-2018 16:01

    My experience has been different. I was with a large hospital group for 5 years and then open my own independent practice. Here in Florida, I had to re-do ALL contracts and get re-credentialled with all insurance companies. Some insurance companies did not give me back access to all prior plans that I accepted before.  This process took months. Medicare took the longest and Cigna was the fastest. 

    Best of luck.

  • 8.  RE: Rookie question re: credentialing with payors

    Posted 05-24-2018 08:12
    You need to call back and ask to speak with "contracting", as your clinic will need the contract. You will also need to be individually credentialed as well. 


  • 9.  RE: Rookie question re: credentialing with payors

    Posted 08-04-2018 03:04

     I am puzzled by these answers re needing to re-credential when going into private practice.

    I work in a hospital now and am starting a cash based practice--no insurances. I was under the impression I had to actively disenroll from the plans. From these responses, it seems that I may not need to do that. Am I interpreting this correctly?


  • 10.  RE: Rookie question re: credentialing with payors

    Posted 08-05-2018 11:55
    I guess for a cash based practice the main advantage of dis-enrolling would be that your name does not appear as in-network when patients are searching for doctors.  This would cut down on phone calls.

  • 11.  RE: Rookie question re: credentialing with payors

    Posted 08-06-2018 15:38
    Your insurance plan contracts remain in effect till one party or the other cancels them.  In your case, your soon-to-be-former employer, not you, would likely be the contracting party, but not necessarily.  Talk to whomever handles physician insurance credentialing at your employer about what their protocol is for departing employees and which insurance plans you will have to contact yourself to sever the contract. Good luck!

    Vahe Keukjian
    Your Family Doc PC
    Ghent NY