Managed Care

Insurance Credentialing: Enable More Patients to Use Vision Benefits

By Eric Botts, OD

The insurance credentialing process is challenging, but a provider for a third-party must be credentialed.Here are key steps to ease the process

According to the US Census Bureau, over 83 percent of the US population has health insurance. The insurance credentialing process can be difficult, but making it through this process successfully is essential to providing patients with service that is covered by their vision (and/or medical) benefit. That means getting credentialed with the right insurance panels for your area and billing medical insurance is a key to growing your practice revenue.

Getting credentialed can be tedious. A Medicare application is a minimum of 30 pages for a solo provider and may surpass 50+ pages if you are a corporation or group practice. Making a mistake in the credentialing application process may delay your acceptance and affect your cash flow, so you have to understand how to do it correctly or find someone who can do it for you.

Note: You cannot be a provider for a third party until you go through this process. Then, the process needs to be re-done every couple of years.
It is important that you are consistent from the beginning so you must decide whether to be a sole proprietorship or corporation before you initiate the credentialing process. Consult with your lawyer and/or accountant to aid this decision. Then you must do the following steps:
• Step 1: Apply/receive state license
• Step 2: Apply/receive Individual NPI #
• Step 3: Apply/receive Tax ID #
• Step 4: If incorporating apply for Group NPI # after receiving Tax ID #

The following information is required for your Medicare application:
•NPI #
• SS #
• Name of optometry school and year graduated
•Optometric license # and state
• Legal business name
• Tax ID #
• Incorporation date and state where incorporated
• Foreign students must use same name on applications as on Social Security card
• Also must provide proof of citizenship or Greencard

When applying to Medicare, a one-owner practice must fill out an 855I application and a multi-owner practice must fill out an 855I, 855B and 855R. The 855I is for each individual, 855B is for a corporation and the 855R allows benefits to be reassigned to another doctor.
Participating versus Non-participating?
You must decide which to do before applying. I recommend being a participating provider because it is more patient friendly and will increase your volume of Medicare patients.
Participating provider status requires that you submit a claim for every Medicare patient and the doctor waits for reimbursement from Medicare. Non-Participating provider status requires that you submit a claim, however you are not required to accept assignment and may collect your allowable fee the day of service. A participating provider receives 5 percent higher reimbursement from Medicare and this is the recommended choice for most doctors.
Many insurance plans require an EFT agreement that allows for automatic deposit of reimbursement checks into your bank account. The name on the checking account should be the same name as on the Tax ID number.
Current Medicare providers who applied prior to July 1, 2011 will be required to revalidate in the future. This involves the following steps:
• Re-submit 855I application and supporting documentation
• Do not need to redo 588 EFT and 460 participation agreement
• Application must be resubmitted within 30 days of receiving letter from Medicare
What is CAQH?
•CAQH is universal credentialing service for many medical and routine insurance plans. Initiate CAQH application by applying to an insurance plan used by CAQH. This insurance plan will issue a number that allows you to begin the application process at
Which insurance plans should you apply for?
Check with the largest employers in your area and consider the plans they provide their employees. Also look at plan reimbursement versus your chair cost to ensure it is a plan that will be profitable for your practice.

Related ROB Articles

Insurance Credentialing: Path to Practice Growth

Enhance Vision Benefit Communication with Patients to Increase Revenues

Pricing Frames Profitably in a Managed Care Environment

Eric Botts, OD, is founder and president of OBC Billing Specialists, and president of InnovativeEyes, in Macomb, IL. To contact him:

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