Depending on what state you’re practicing in, you may be facing challenges as you try to obtain the insurance contracts you need and want to serve your community. Whether we like it or not, a majority of our patients are paying a pretty penny for their insurance coverage. This means that they’re going to seek out providers who are in-network with their insurance carrier. The more you understand about how this process works, the more likely you are to be successful to get in-network with these carriers so you can better serve those in your community.
Create A Quality Division
The quality division enforces policies and ensures compliance across admin and clinical staff. The Quality Director typically coordinates education and compliance – both regulatory and operational. The Quality Director ensures the staff has the same experience being on-boarded, they enforce policies – not just the P&P manual but also regulations. They should know HIPAA, Medicare and other insurance regulations at a state and federal level so that they can not just educate but also enforce.
They will manage the peer-to-peer review system both on the clinical and administrative side to ensure medical necessity, and that progress is being seen towards short and long term goals. This information – from audits and stat grids – showcases the effectiveness of your staff but also shows how you’re constantly educating them to be better clinicians.
In addition, to maintain compliance across the staff, they will track success across the staff stat grids. Their job is to provide education based on the statistical trends because once you evaluate and train, the net result is increased performance. They should be asking “How can we enhance the quality of what we do for our patients?”
Show the Need in Your Community
Obtain at least five medical doctor letters that state that they wish to use your services but that their patients have been adversely affected due to lack of access by your practice not being in-network.
Subsequently, get letters from 10 patients stating their dissatisfaction with your services not being accessible by not being in-network.
Find a Niche
Seek to provide a unique specialty service that is not being done within a 5-mile radius of your office such as occupational therapy, speech therapy, pediatric therapy, TMJ, aquatic therapy, dry needling, just to name a few.
Outsource the Contracting and Credentialing Process
While contracting is the credentialing of your clinic, you will need to credential your individual therapists as well. Credentialing and/or re-credentialing has become a very in-depth and detailed administrative burden on most practices that accept insurance. Pay a group to do it for you where they are professional and that is all they do – it’s worth every penny. We always recommend outsourcing any clerical or administrative activities that are time-consuming and take you away from the important duties of running a private practice.
If you are being treated poorly by insurance companies, be sure to report this to your insurance commissioner as well as your state APTA chapter and the National APTA. Finally, check to see if your congressional or state representatives can assist – often they have constituent services that can help navigate bureaucratic red tape.
Whether you’re a startup, or are expanding and want to be in more insurance networks to serve your community better, there is a lot of value to understanding how the process works. Contact us to learn more or find out how you can outsource this important task to opening or expanding your practice as well as the process of credentialing individual therapists.