Credentialing and Insurance Specialties
Specialties don’t make you special to insurance companies that is.
One of the most common questions I hear in credentialing after an application is denied is “But I do (blank), and no one else is my area does. Shouldn’t I get credentialing because of this?”
Unfortunately, the answer is often “no,” and it has more to do with the insurance company than types of insurance specialties. The reasons are many and are important for providers to understand in order to better prepare themselves for working with managed care.
The Insurance Company doesn’t need your Insurance Specialities.
Let’s start with the shortest, most brutal explanation: your specialty (or specialties) is not something that they care about. I think the best example of this (and there are many) is Yoga Therapy. Even if it is the most requested form of therapy in an area where you are the only provider within 50 miles, it is not going to get you credentialed.
You may become in network for other reasons besides specialties like this, but it just not a treatment modality that insurance companies are interested in.
Competition
The next reason is that many other providers in your area may have the same specialty as you. The best way to avoid this is to research your competition in the area before you establish your practice and be aware that many specialized clinicians may not feel the need to do marketing.
One key thing to be aware of is that having training or a national certification will always trump experience on a resume when it comes to proving your skills to an insurance company. This is simply because certifications require a known quantity of training, experience and tests. Unfortunately, the quality and effectiveness of the work you did at a certain place is almost impossible to prove.
Location
Finally, insurance companies have their own algorithms and policies to determine how many of which type of provider they need in a geographic area. This is based on the number of members in a given region, so it is very common for insurance companies to perceive no need in their network for what you provide.
Still, your perspective as a working clinician might be that the community is underserved for your specialty, and it is important in these instances to inform the insurance company of the discrepancy between your view and theirs.
In addition, gaining certifications in specialty areas are a great way to define yourself as a clinician and will always make you a more attractive candidate for credentialing. Remember, however, that it is important to do your research into what insurance companies are looking for in your area before committing the resources (both time and money) to getting certified.
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Hello, this is Ben. I’m glad that you liked the article, and those are great questions! I am referring to certifications. Certificates can be helpful in meeting requirements (for example, EAPs often require training in substance abuse), but certifications demonstrate that you have a standardized level of knowledge on a certain subject since they require some sort of test to obtain.
As to your first question, it is very hard to figure out which specialties are best in your region. There are several reasons for this: Many companies are unwilling to inform you what they are looking for because people may inflate their abilities to get credentialed. For other companies, it is a matter of reaching the network manager. Since they decide which providers will be credentialed, they will know the gaps in their network.
Be aware though. They do not have to give that information out. However, contacting them can be very difficult for individual providers. This is one of the advantages of hiring a credentialing company like Thriveworks: We either know the person to talk to, or are very good at finding them.
The best way to determine the need in your area is to think like the insurance company: Look at what other providers in your area offer, as well as the needs of the population. If you do this objectively and can come up with solid numbers, then there is a chance even a closed insurance panel will accept you upon appeal.
Hope this helps! -Ben Baynton
Excellent info. However, how do one find out which certificates/certifications are needed in their region? And, are you speaking of certificates or certifications?