EPISODE SUMMARY
This episode of The Claim Game, "Accessing the Board," features an insightful interview with Cathy Gilbert, an expert with over 30 years of experience in the healthcare industry, including leadership roles at major national payers like Magellan and Beacon Health Options. Cathy shares her unique perspective from the payer's side of the table, demystifying the complex and often frustrating world of credentialing, contracting, and fee negotiations for private practice owners. She explains that while the process can seem like a "black hole," there are rules, and understanding them is key.
KEYWORDS
Credentialing, Provider Network Management, Contracting, Revenue Cycle Management, CAQH, Timely Filing, Rate Negotiation, The Claim Game, Practice Solutions, NCQA, URAC
TAKEAWAYS
Payer's Perspective on Credentialing: The credentialing and contracting processes are two pieces that go hand in hand. Payers have a cost associated with credentialing and want to ensure a provider meets their minimum requirements for licensure, education, and liability insurance before investing in a contract. They're also looking for a need and volume that can support both the provider and the plan's time spent on the process.
Keep Your CAQH Up-to-Date (It's a Dual Effort): A provider's CAQH profile is considered the "gold standard" for credentialing data. It's the provider's responsibility to keep it current and accurate, as plans can and will use this data. Failing to respond to plan requests for information could result in being removed from the network.
The "Black Hole" of Credentialing Has a Lifespan: The credentialing process typically takes 90 to 120 days to complete. A provider's application signature will expire after 120 to 180 days if not processed, requiring the provider to resubmit. Providers should track their application status through the plan's portal and only follow up if the timeframe on the website has passed, as calling earlier will likely not speed up the process.
Relationships Got Taught Out of the Payer Role: While people who work at plans genuinely want to help, their teams are small relative to the number of providers they manage. This has led to a shift away from in-person relationship-building to a more virtual, centralized approach.
You Can Get a Direct Payer Contact: Provider relations representatives are assigned to specific territories, and their information is often publicly available on a plan's website or in the provider manual. You can also search for these contacts on LinkedIn.
Rates and Terms May Be Negotiable: Rates may be open to negotiation, especially for in-demand specialties like child psychiatry or in areas where the plan needs to expand access to care. In terms of contract language, timely filing limits are often negotiable. For any negotiation, be aware that it will likely delay the contracting process.
Big Therapy Tech Firms and Their Rates: Tech-enabled firms were able to negotiate higher rates during COVID-19 to provide access to care. However, plans are now pushing back and renegotiating these rates, particularly for providers already in their network. This creates a unique opportunity for independent private practices to negotiate rates by highlighting that they can add "net new" providers to the network.
Payer Quality Standards Impact Your Practice: Plans are measured on quality metrics like the HEDIS measures. One of the most important metrics is getting a patient into care with a community-based provider within seven days of being discharged from a higher level of care. Some plans offer higher rates to providers who can consistently meet these kinds of standards.
The Power of an EOB: The Explanation of Benefits (EOB) is a power tool for providers. By understanding the "Allowed Amount" on an EOB, you can spot discrepancies and determine if you're getting paid correctly, which is a key to taking control of your revenue.
The Value of the Hourglass Learning Hub: The Hourglass Learning Hub is a comprehensive platform designed to simplify your billing machine. It provides educational articles on key RCM domains, DIY billing resources, and an "Ask the Biller" feature for personalized video responses to complex questions.
CHAPTERS
00:00 Introduction to Credentialing and Provider Networks
03:25 Cathy Gilbert's Journey in Healthcare
05:44 Contracting & Credentialing: The Two Sides of the Payer Process
07:36 NCQA, URAC, and the Accreditation Game
09:36 What Payers Look for in Network Providers
13:48 Measuring Quality in Provider Networks
15:23 CAQH, Compliance, and Network Clean-Up
18:35 Navigating Contractual Obligations
22:17 The Credentialing Timeline Explained
26:23 The Relationship Between Providers and Payers
26:26 Breaking Through Credentialing Roadblocks
33:41 The Right Way to Follow Up on Credentialing
38:39 Navigating Provider Relations and Contacts
41:27 Reading the Fine Print: Contract Clauses That Matter
47:07 Negotiating Higher Rates with Health Plans
52:35 Rate Negotiations and the Power of Transparency Data
57:12 Aggregator Rates, Payer Power, and the Future of Therapy Contracts
01:03:58 Conclusion: The One Rule for Credentialing Success
RESOURCES
The Hourglass Learning Hub: Dive deeper into RCM best practices and downloadable tools mentioned in this episode, like the various checklists and templates, by visitingThe Hourglass Learning Hub.
Learn More About The Claim Game: Visitpracticesol.com/podcast
Our Blog: Explore years of educational articles on billing and practice management atPractice Solutions Blog.
Book: For a comprehensive guide on navigating insurance, grab your copy of Insurance Billing Basics: Steps for Therapists to Successfully Take Insurance.
