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Session 1: Becoming An In-Network Insurance Provider

In the last few years with the Affordable Care Act, nutrition counseling has become more widely covered by many health plans across the country, with more medical conditions and higher number of visits that are now being reimbursed. Since 2015, nutrition counseling is considered an essential benefit in 26 states under preventative services, so areas like weight management, hypertension, and other areas that were not previously covered can now be reimbursed.  In some of the major health plans in certain states, unlimited visits are even fully covered.

 
 

Becoming an in-network provider enables private practices to grow quickly because it increases your likelihood of clients and gives you a 62% higher chance of converting a paying client when compared to private pay.  Let’s step through some of the ways to get started if you are considering becoming an in-network provider.

1. Research reimbursement in your area

Begin by making a list of all of the insurance companies in your city and state, so you can find their contact information to inquire about their coverage.  One great place to start is searching in your area on eHealthInsurance for types of plans that are available. Another good place to start is with some of the major national health plans, which include: 

  • Aetna
  • Cigna
  • Blue Cross Blue Shield
  • Anthem
  • United HealthCare

Medicare is also another great option to accept insurance. While they are often limited to coverage for Diabetes and Renal disease (and if done in a primary care setting, obesity counseling), it is definitely still worth becoming a Medicare provider because the 65+ age group will be the ones are most likely the ones who will need nutrition counseling.

Once you've made your list, contact each health insurance company to obtain an application to become a network provider and find out the following before proceeding:

  • Network status in accepting dietitians
  • Contract terms
  • Eligible medical conditions
  • Fee schedules

Most of the time, dietitians find that contracted rates are very comparable to private pay rates. To get a better idea, you can find out what the average reimbursement rate is for your local area by looking at the Medicare Fee schedule, which is typically the average rate of insurance reimbursable rates in the specified location and set at 85% of the reimbursed physician rate.

 

2. Credentialing

Once you’ve determined that you can proceed in becoming an in-network provider with a health insurance company, the next phase is to become credentialed.  Before you begin this process, your business entity must be appropriately set up as the following are part of the required information that you must submit:

  • EIN
  • NPI
  • Proof of liability insurance

Note: Please refer to Module 2 if you need to go through all the appropriate steps of setting up your private practice

CAQH also provides a standardized application to make it easier to be credentialed with multiple health plans with one application process. Your CAQH information can be stored and maintained for submission to your selected health plan organizations. This can help save you time by allowing health plans to directly access your credentialing information.

*Note: You still have to contact each insurance company to obtain and fill out a specific application for each, which will then permit the insurance company to use your CAQH information.

3. Contracting

Once the credentialing portion is submitted to the health insurance company and the provider network is open, you will move into the contracting phase with the health insurance company.  

The contracting phase can be a lengthy process, and in general, can take anywhere between 2 to 8 months. Sometimes, you may even find out that the provider network becomes limited or closes while you are waiting. It is also helpful to apply to multiple insurance companies at once, as you will be more likely to get through the process with at least one insurance company to jumpstart your practice while you wait on the others.

While you are waiting to hear back, you can consider the following: 

  • Advertise on your website that you are in the process of credentialing to become an in-network provider. 
  • Consider starting a wait list for clients who want to use insurance to work with you, and inform them to set up an appointment as soon as you confirm with the insurance company.

Once you are successfully contracted with an insurance company, the next steps are as follows:

  • They will contact you and send over paperwork for your signature through email or regular mail.  
  • Ask them to provide a date in which you will become active in their system. This is the day that you can begin accepting insurance-covered clients and submitting claims.
  • Each insurance company will list you on their provider directory so that their insurance members will be able to find you.

 

 

Getting help with credentialing and contracting

If you don’t want to deal with the hassle of paperwork insurance credentialing and contracting services, such as Healthy Bytes, offer services that help dietitians with the credentialing and contracting paperwork for a fee, as well as a HIPAA-compliant online platform where you can submit and receive eligibility checks for your patients and quickly submit claims.

  • Contact them and see if they are the right fit in helping you contracted with insurance, help you negotiate a competitive contract rate, and make it easier to submit claims with their service so you can focus less on claims paperwork and more on your clients!  
  • We highly recommend you checking on your own on the status of any open networks before deciding to use Healthy Bytes' contracting service. Even with the help of Healthy Bytes your ability to get contracted is ultimately on whether the insurance company has opened their network, which can sometimes be a very narrow window.  

What if you can't become contracted as an in-network provider?

As some of you may have found, certain states are difficult to become contracted with major health plans. The typical rule of thumb is that if your state does not have licensure, you may find that networks are closed often times for stand-alone private practice dietitians. 

One way that you may be able to become an in-network provider is to go under the umbrella of an existing health care practice that already accepts health insurance (whether it be a medical, chiropractic, or a dietetic practice). That means going through the lengthy credentialing and contracting process under another practice in order to starting seeing their patients; you will also be employed as a contractor or employee by the practice.  Owners of the existing practice may take ~20-40% rate for patient consultations billed through their practice. Part of that cost may include: 

  • Liability insurance coverage (Note: this would only cover liability for patients you see through their practice.)
  • Helping you handle your claims billing
  • Office space

Despite taking a fee or rate, it may be a great way to help you jumpstart a client base and is a viable option to consider. View this as a partnership situation where they may be helping you gain momentum to start seeing clients through another practitioner's patient base.