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Supero Healthcare Solutions Provider Enrollment and Credentialing Blog

Provider Enrollment - Tips for Success - Choosing Contracts (Step 1)

Posted by Brian Agnew on Tue, May 31, 2011 @ 21:05 PM

Normally when I start a provider enrollment project for a client, the first question I get from the provider, is "which contracts do I need be credentialed for in my market."  There are the usual payers like Aetna, BCBS, CIGNA, Humana, UnitedHealthcare, Medicare, Medicaid, and TriCare.provider enrollment

These are usually a good rule of thumb to start with in nearly any major market.  Beyond these, you will usually see a local plan or two that you might want to contract with as well.

The number of contracts is not as important as the quality of contracts.  

For the normal practice, you might see 15% to 25% of your patients through Medicare or Medicaid depending on the population you serve and where you are located. After that, it is normally 7 or more commercial payors that will drive 70% or more of your patients to your practice.

Two contracting vehicles to be aware of are a PHO (Provider Hospital Organization) or an IPA (independent Physician Association).  Many of these types of contracting entities can offer up to 20 plans as part of their contract offering.  With this kind of model, the provider fills out one application and signs one contract.  This is good, because it cuts down on the amount of paperwork.  The downside is that these entities don't usually have contracts with the large payors.  It will be an opt-in/ opt-out scenario in which the provider chooses which plans to participate. If the plans you want are not included as a choice, you will need to pursue direct contracts with those insurance companies not included.

Another tip for choosing contracts is to see who your referring physicians are contracted and credentialed with.  If you are a practice that markets to another practice for referrals, one of the first questions your marketing person will get is what health plans are you contracted with.

If you don't really have a way of knowing which plans to contract with, there are consulting groups such as our company, who offer provider enrollment services and can help you develop a contracting strategy.  

If you need assistance in choosing which insurance companies to contract with, click here to contact our office today!

Brian Agnew is President of Supero Healthcare Solutions a leading practice management company focused on provider enrollment and credentialing services for physicians and other healthcare providers.


Topics: Provider Enrollment, Payor Contracting, Payor Credentialing, Provider Enrollment Services, Physician Credentialing, Medical Credentialing, Managed Care Contracting and Credentialing, Credentialing