By Eric Botts, OD
According to the 2010 US Census Bureau over 83% of the US population had health insurance and that number is growing rapidly as a result of the Affordable Care Act, which means being credentialed with the right insurance panels for your area is a key to growing your practice revenue. Unfortunately the credentialing process can be a daunting task. 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.
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 credentialing process. Consult with your lawyer and/or accountant to aid with 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 requires you submit a claim for every Medicare patient and the doctor waits for reimbursement from Medicare. Non-Par provider requires 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% 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 1st, 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 a universal credentialing service for many medical and routine insurance plans. Initiate CAQH application by applying to insurance plan used by CAQH. Insurance plan will issue a number that allows you to begin the application process at www.caqh.org.
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 insure it is a plan that will be profitable for your practice.
Photo: Copyright: rido / 123RF Stock Photo
Eric Botts, OD is in practice at the InnovativEyes clinic located in Walmart Vision Centers in Macomb, IL, Galesburg, IL and West Burlington, IA. He is also President of OBC Billing Specialists located in Macomb, IL. This service helps credential doctors and submit routine and medical claims for optometric practices that choose to out-source their billing needs. He also lectures extensively on medical billing in an optometric practice. He may be reached at 309-333-6344 or firstname.lastname@example.org.