You just graduated from a school of optometry and decided your practice location. If you plan on examining patients who wish to use their vision and medical insurance, you must be an ‘in-network provider’ with that insurance company. According to the US Census Bureau, over 83 percent of the US population has health insurance. This means getting credentialed with the right insurance panels for your area and billing medical insurance is a key to growing your practice revenue.
You need to start as soon as you have your license and location to practice. Your reimbursement will depend on which insurance plans you will accept. Most medical and vision insurances have their own credentialing processes and procedures. You have to plan your credentialing process. Sometimes, optometry credentialing can be a long and difficult process, leading to frustration. In this article, we shared the basics you need to take to get credentialed with medical and vision insurance plans.
Medical and Vision Plan Paneling
Apply/Receive State License
An optometry license granted by each state’s regulatory board of optometry must be obtained upon graduating from an accredited optometry school for optometrists to legally practice in the United States. Obtaining an optometry license varies from state to state in regards to fees, requirements, and application processes.
Obtain an NPI #
In order to be a Medicare provider, a doctor of optometry must obtain a National Provider Identifier (NPI) number. While applying for NPI # make sure that you are using your legal name as listed on your Social Security Card. You will have to list your Social Security number on your NPI application. Note that you have to mention practice location in the NPI application. So deciding a place to start your practice becomes crucial. Instructions for applying for NPI # can be found at: http://bit.ly/3i9PwMj
Apply/Receive Tax ID #
After you have decided if you want to be a sole proprietor, an LLC, or a Corporation, you can apply for the tax ID using whatever name you choose for your legal business name, and the type of business you will register as. Once you have received the tax ID, you are now ready to set up the LLC or Corporation. You can register the LLC or Corporation on your state’s Secretary of State Website.
Apply to CAQH
Almost all insurances except Medicare and Medicaid require that you have CAQH and that it is up to date. Credentialing is the administrative process for validating the qualifications of licensed professionals and assessing their background and legitimacy. CAQH is a credentialing agency that is used by many health plans. CAQH is a centralized resource that houses all of a provider’s information in one place and it eliminates duplicate paperwork. You can visit the CAQH website to apply for credentialing: http://bit.ly/2KhnFgG
Determine Vision Insurance Plans
There are many different plans to consider joining. Some of the questions you need to ask yourself before joining a panel are:
Major Insurance Plans:
Identify the major plans in your geographic area. If the majority of the population in your practice location has a certain plan, it would make sense to become a provider. On the other hand, if there are virtually no patients covered by this plan in your area, question whether it would be worth your while to become a provider for that plan.
Understand Plan Requirements:
Each plan is organized differently with its own procedures and claims processes. Some plans are definitely easier to work with than others. Read application instructions thoroughly, and check additional and specific requirements for each plan to which you are applying.
Do some research on reimbursement rates in your area. This research would be helpful for negotiation at the time of contracting.
Complete a Medicare Application
Most insurance plans that contract with doctors of optometry require a panel applicant to be a Medicare provider first. The Medicare application is a lengthy document. 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. Medicare enrollment application forms are fillable on your computer.
However, signatures must be handwritten. Upon acceptance of your Medicare application, a Provider Transaction Access Number (PTAN) will be issued. For further instructions, visit this website: http://go.cms.gov/39BVnpU
Credentialing with Private Payers
Most insurances have detailed credentialing information on their websites and a contact phone number for more assistance. They have a separate credentialing and enrollment department for providers who wants to become in-network. If you have a good referral relationship with an ophthalmologist, a good strategy is to seek their assistance in getting approved.
They could sign a letter on your behalf indicating that it is important for you to be put on the panel for continuity of care with mutual patients. Ultimately you, as the provider, must decide how many insurance panels to apply for. Figure out what type of practice you’d like to have and what type of patients you’d like to work with, and you’ll be able to decide what the right direction is for you.
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