In this episode of the Talking Tech Podcast, Jennifer breaks down a popular question – “how do I get my ultrasound business credentialed with insurance?”
Listen in as she dives into:
Credentialing itself can be a confusing process, and this episode is geared toward helping listeners understand the steps and strategies behind it.
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Welcome back into the podcast. I’m so excited. This episode, I am chatting all about what it looks like to get credentialed with insurance for your ultrasound business. It’s a question I get all the time. It’s a question I dive deep into with my clients and I want to give you some insight today on what that actually looks like. So if you are looking to provide, let’s say, either mobile ultrasound services out at physician practices or facilities where you are the one billing insurance directly or potentially you have your own facility clinic and want to be able to offer services where you are billing the patient’s insurance directly. I want to talk a little bit about what that looks like. Some of the questions that I have gotten are, do I have to, what do I have to do? Do I have to be set up with insurance companies?
Some people think they just need to partner with a billing company and the billing company can do all the things on behalf of them. So I want to just clear up what that actually looks like. So for you to be an in-network provider with insurance companies, for you to be able to submit claims for that patient’s ultrasound and to get paid from insurance for those services, you need to be credentialed as an in-network provider with the insurance companies local to you. So one of the first things to figure out is what your top five or six insurance payers are in your area. So here for us in Indiana, ours major ones Medicare, Medicaid here in Indiana, so yours would be called something different. That’s a state run program and that would look something different like in California, I believe it’s called Medi-Cal. So look up the one for your specific state here in Indiana, we call it Medicaid and we have Blue Cross Blue Shield.
Cigna is a big one here as an example, right for you. So figure out what the major payers are in your area because that’s kind of step number one is figuring out who would I actually even need to get credentialed with. Now I will create a huge caveat here. I do not suggest trying to do this on your own as business owners, and I know I have fallen into this trap many times, especially in the start of our business where it’s like, okay, I am trying to save as much money as possible, so I kind of know the gist of how to do this or how to do that. I’m going to try it on my own. Credentialing is one thing I would say, please do not try to do it on your own. Hire someone to do it. It’s why it’s one of our vendors on our vendor list for our clients in the Ultrasound Business Academy because we want, if they want to get credentialed for them to not have to do it on our own and to not have to find someone to do that.
Usually a billing company is going to be able to also credential you and usually they have a fee per insurance payer that you are looking to work with to fill out all the paperwork for you, get all your numbers, put together, all of those things. There are a multitude of things you’ll need like to be listed on CAQH, you’ll need an NPI number. There’s a multitude of things outside of just getting credentialed and a billing company is going to have a checklist for exactly what you need to do. I say that because yes, it will save you money to do it on your own. However, it’s going to take you a lot of time to figure out where do I even get the paperwork to get credentialed? What’s the process to do that? What if I have questions about the applications? All of those things, if I fill it out wrong and I turn it in and they don’t get to my paperwork for three months and then they realize I’ve made a mistake on one line here and they have to send it back to me, now I got to wait another three months in their queue with the appropriate proper setup.
So it makes the most sense. Everything in business costs us either time or money, and so spend the money on this because in the end it’s going to save you so much time and heartache getting this put together. So my suggestion, again, partnering with a billing company to be able to do that credentialing for you, figure out those top five or six payers in your area, and then the way the process looks is that company is going to request the paperwork to be filled out that they would complete for you and they’ll let you know exactly what they need from you to be able to complete all of that paper. I’m going to give you, get out a piece of paper and a pen because I’m going to give you the form for Medicare credentialing. Okay? So if you are set up as a mobile IDTF, which as a non-physician practitioner, that’s how we are going to set up our businesses, providing mobile ultrasound.
This is also the same form you would use for a facility like standalone IDTF as well. You would just set the information in there whether or not you’re doing mobile or standalone facility, but it’s the same form. It’s form CMS 855B. Okay? So C as in cat, M as in Mary, S as in Sam, 8 55, B as in boy. Just Google that form, it will pull that up for you. Print it out and just swipe through. Take a look at what you are going to need, kind of step number two. So step one, figuring out all of the insurance, major insurance payers in your area. Step two, print out that CMS form 855B. So ahead of time, the things you’re going to need. One of those things is a medical director. It’s called in that form a supervising physician. So we kind of use those terms interchangeably, but you’ll see it listed as a supervising physician inside that form.
That is someone who can actually supervise you. So I want you to look at what the requirements are for your supervising physician and that is going to give you an idea of what that looks like. Usually it’s the radiologist or cardiologist, OB, right? If you’re, that’s all you’re doing, the person reading your studies is the best place to start for the supervising physician role. What that kind of looks like is usually there will be some sort of monthly fee to be your supervising physician. They are taking on some liability supervising your practice. And so there’s usually a fee involved with that. It makes the most sense to, again, speak with a person or people that are doing your interpretations to see if they are able to provide that supervisory role. That’s the best place to start. It makes sense for them to be a supervising physician to gain additional reads from you, the more you are able to provide inside your market, right?
Providing services now, not only to self-pay patients, but if you’re credentialed with insurance, now you open your market up to insurance-based patients as well, that increases the amount of reads that they could potentially get from you. So that’s the benefit to the supervising physician. That’s why it’s always the best place to start is with those people that are already interpreting your studies because it benefits them in that way. Now they need to be able to actually supervise you. So I have a lot of people that say, Hey, I’ve got a friend who is an internal medicine doctor or a general practice doc and they said they’d be my medical director. That’s great, but if they can’t actually supervise you, they need to know is this person scanning appropriately? Are they working through protocols? Do we have a quality assurance program set up? So those are the kind of backend things that they need to be able to do.
So again, look at what those roles require inside that form to give you a better idea of who is the best fit for a supervisory position with your practice. That’s the best place to start there as far as figuring out what all you will need. And then a lot of the credentialing paperwork for the insurance companies outside of Medicare. So all the private payers like Blue Cross Blue Shield, Cigna, Sagamore, all of those, they usually follow pretty closely suit with Medicare. So if you see it in the Medicare requirements on that form, likely you’ll have pretty much all of your bases covered as far as what you’re going to need to have in place to be able to submit that initial credentialing paperwork. So the billing company will get what they need from you. They will create the finalization of all of those requests for credentialing, right?
All the things, the paperwork they have to fill out there to request that. You become an in-network provider with that specific insurance company. They send all of that in. Now, unfortunately at this point, we are at the mercy of these groups, and so it is all about just getting into their queue. Some will take 30 days, some may take six months, right? We never know what that’s going to be. I suggest asking the group that’s doing your credentialing, if there’s a way to find out when they are speaking with the insurance companies to figure out if they know the fee schedule, if they can get that for you, the fee schedule would be the list of the allowables that you are going to be paid for each specific CBT code, okay? And also what their queue time is. How long is the approximate time I would be inside the queue.
The other thing to try to find out from them as well is whether or not the panel is open or closed. And what I mean by that is that some insurance companies, this happened to us in our own ultrasound business years and years ago when we first initially started trying to get credentialed with insurance, the panels were closed, so we submitted our paperwork on our own. See, I tell you guys this all the time, we make a lot of mistakes so that you guys can skip over all of our expertise, all of the things that we did wrong, and I can tell you, Hey, don’t do it like this. This is the best way to do it. And I know it from experience. So we filled out our paperwork on our own, sent it in. I think one of the first ones we got back was Blue Cross Blue Shield, and they said, thank you so much for your application.
The panels currently closed. We are not accepting any providers at this time. So please note that that can happen, right? You are not guaranteed a spot as an in-network credentialed provider just because you sent your paperwork. The panel has to be open and they have to be accepting new providers to be able to get credentialed. Now, let’s say everything goes perfectly. The group sends your credentialing paperwork in, you get a response back that you have been approved as a credential provider. They will send a contract that lists out all of the information about how you’re going to get paid, what you’re going to get paid, and you are able to negotiate those rates. Now, not always will they accept the negotiations, however, that’s something that you can absolutely work with your billing company to do. If you feel that you want to negotiate the fee schedule rates that you’re getting back in the contract, you would then sign that contract.
They would let you know next steps for getting things set up, and then at that point you would be credentialed as an in-network provider and could start submitting for reimbursement that second then step of this is to work with that billing company then to actually bill for the ultrasounds that you are providing. That is something that unless you’ve billed and you know how to do that, you are not going to know how to do proficiently enough to ensure that you are going to get reimbursed. And so it makes sense, again, time or money, either making yourself super knowledgeable, getting all of that information that can take months to do, right? To teach yourself how to do this, or you can just pay someone to do it, right? Highly suggest initially when you start to pay a billing company to submit claims for you. So they will submit claims on your behalf.
They will. Then the insurance companies, when they pay back, you can set things up to ACH direct to your bank account, which I highly suggest as opposed to having them mail you checks right in the snail mail. That’s an opportunity as well. And some of the smaller payers, that’s all they do is mail checks, right? We have some smaller payers that we are credentialed with just because it’s our local groups that we see quite a few patients from, and some of them don’t have ACH option, and so we get paper checks in the mail, but obviously it’s going to be way quicker to get your money into your account if you set up ACH. So if that’s an option, I highly suggest doing that. And then your patient always has a portion as well. So as an example, for my insurance, I have an 80/20 plan, which means that once I hit my deductible, I owe 20% of the allowable.
Now I’m going to do a whole other podcast on billing. Actually, the billing portion, right now we’re just talking about credentialing, but the billing portion. So if the allowable for the ultrasound I got was a hundred dollars to make the math easy for me, my insurance company, if I had already hit my deductible, my insurance company would pay back the provider that I went to for my ultrasound, $80, 80% of that $100 allowable. I then get a bill for my provider for the other $20. So the allowable for the provider is a hundred dollars. Insurance covers $80 of that. I cover $20 of that as my co-insurance as the patient because I have an 80/20 plan. Some people have an 90/10 plan, most insurances are at 80/20. So just know that. Then you would get the money back for the 80% as the example is here from insurance.
And then you would need to send patient statements out to your patients for any portion. That’s their co-insurance. Now, sometimes imaging is applied to a deductible. So if a patient hasn’t met their deductible yet, which happens a lot in the beginning of the year, we see this always in January, February, especially with our business, they have not met the deductible yet. And so that $100 then is the patient’s responsibility. In this example, right? The allowable was a hundred dollars. If the patient hadn’t met their deductible and imaging was applied to that deductible, the patient would owe a hundred dollars. So I’m waiting back for the EOB, the explanation of benefits from the insurance company that says the allowable was a hundred dollars. We’ve paid zero because the patient owes this towards their deductible, they owe you a hundred dollars. So it’s going to depend on how every individual patient’s set up with their insurance company, whether they’ve met their deductible, and that is why.
Another reason I highly, highly suggest hiring a billing company that can take care of all that backend for you. So the process itself when you hire someone to do it is fairly simple. You need to find a medical director, a supervising physician. You need to figure out what your top five or six payers are in your area to start out with. You could do more than that if you would want to, but it is going to cost you per payer to get this set up so it makes the most business sense to just figure out what those top payers are, get credentialed with those, and then you can add in the smaller payers as you go. So find your supervising physician. Number one, figure out what your top payers are in your area so you know who to get credentialed with, and then get the paperwork information, all of that over to your billing credentialing company. They’re the ones that are going to send everything in. You’ll find out once it’s submitted, if the panel is open or closed, if you are accepted or not as a credentialed provider, and at that point you can start billing insurance directly. I hope this was helpful. It’s a question I get on the regular, so I wanted to break it down here in this podcast. Thank you so much for listening and hanging out with me today.
your strategy-obsessed ultrasound business coach.
I'm Jennifer -
Welcome to the Talking Tech podcast, where we answer your questions about legal, marketing, admin, sales, and so much more. After nearly 20 years in the industry running our own mobile ultrasound business and helping techs across the country do the same, I'm so excited to bring you industry insight, mindset, productivity, business tips, and inspiration to help you design the business of your dreams.
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