Texas Medical Board
www.tmb.state.tx.us
DEA
www.deadiversion.usdoj.gov
TMLT
OMIC
www.omic.com
The Doctors Company
www.thedoctors.com
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• Provide all requested information in a timely manner (we will provide list). The physician information must be accurate.
• Curriculum Vitae (CV) needs be in MM/DD/YYYY education and work history. The CV needs include the start date of the practice under current employment before submitting it to the insurers.
• It is very important to return signed application(s) as quickly as possible. Any requests received from the health plans/hospitals forward to us immediately.
• Licenses (all current with correct address),
• DEA certificate and DPS certificate with correct address
• Malpractice insurance face sheet and Declarations page -with your business address listed
• History of malpractice coverage
• Claim explanation(s) documentation along details of claim
• Board certificate(s)
• Clear copies of Medical Diploma/Intern/Residency/Fellowship certificates.
Credentialing is the process of getting a physician approved by hospitals to obtain privileges and approved by health plans to become a participating “in network provider”.
Hospital privileges
Hospitals grant privileges to physicians and other health care providers to use their facilities for patient care. Obtaining privileges should be the first step in credentialing, hospital privileges are essential for health plan credentialing. Since health plans maintain networks of a variety of physicians and hospitals, it is preferred physicians have admitting privileges at a participating hospital, if not it is required that the physician have a designated alternate that is participating on the plan that has agreed to admit patients on the physicians behalf or have a Hospitalist group at an in network facility.
Hospital privileges are specific to a physician’s specialty practice expertise. Before granting privileges, hospitals will complete an extensive verification for a physician’s credentials according to JCAHO standards. This process can take anywhere from two to six months sending on how quickly they receive back the verifications, in certain circumstances it may be possible to obtain temporary privileges. Once all information is received, the hospital’s credentials committee will review the information and verify the file is complete. The completed file goes to the hospital’s medical executive committee for approval and then presented to the board of directors for final approval.
Becoming a participating provider
Health plans create networks of participating physicians of all specialties, hospitals and labs etc., that have agreed to provide services to their members. The health plans require the physician who wish to become participating providers to complete their credentialing process. Majority of health plans will require the physician’s credentials to have been verified and the health plan’s credentialing committee approves before they will forward a contract to the physician for review/signature. Other plans will send a contract for review/signature then once the health plans have received the signed agreement they will at that time start the credentialing process. The entire process from start to finish can take anywhere from 30-180 days or longer if negotiating the contract applies.
Once the physician has become a participating provider it is so very important that a physician’s demographic information as in office location(s), Tax ID#, NPI# and specialty is verified that it is loaded correctly in their data base. If it is not loaded correctly many issues will occur that can be costly to the practice.
TLPS Fees & Prices
Prices for our services vary depending on the size and scope of the project. Here is some additional information which may help in you in your search for the right credentialing company!
New Practices
Please call or email us to find out our current pricing. We have packages to fit every budget and custom design every proposal based on the most time sensitive credentialing needs you may have. We have a flat fee which covers our most common services and is based on the number of providers in the group and the number of insurance companies that need to be set up. We also offer a la carte pricing which is billed per hour or per insurance company if we are doing contracting. We can typically send a proposal out after of receiving your information.
Existing Groups
We have various packages that we create for growing expanding practices. Pricing for these packages is based on the number of providers in the group and scope of the project. You are assigned a manager to your account and you either pay hourly or by means of a monthly retainer. Our hourly fees vary depending on the staff member(s) who are assigned to your account.
We apologize for not providing more direct pricing but we provide an a la carte service that is based on the unique specific project requirements. Contact us to find out more about the various service offerings.
When it comes to negotiating fees with health plans, practices and physicians have more leverage than they realize. The problem, is that practices often don’t even try. “Groups negotiate an agreement with a payor and then, for whatever reason, just file it away. Most medical groups do not have a good, proactive methodology for negotiating for physician reimbursement,”
There is a Adversarial fee negotiating environment that has existed between physicians and health plans is changing to a more cooperative partnership between payors and providers. As an example, of a physician group whose contracts were renegotiate. When contacting the medical director of the group’s largest payor and indicated the group wanted to renegotiate its contract and fee schedule, and suggested talking about a pay-for-performance arrangement. Not only was the medical director receptive, but also arranged to meet with members of the physician group to further discuss the arrangement. “What used to be a poker game is now transparent. The realization is, we all have an economic problem with respect to medical costs. But the doctors have the clinical solutions to those economic problems. Health plans are saying, ‘Let’s see if we can’t be better business partners not only for our sake, but for the sake of the patients and the community as well.’ It’s a new era of managed care, which is really what it should have been when it kicked off twenty years ago.
There are several ways physicians can begin renegotiating fees with health plans. If a physician is hospital-based, he or she has a little more leverage. For example, the physician is performing services at a hospital and being paid the health plans’ usual, customary rates for that location. The physician asks for an increase, and the health plan says no, so the physician cancels his or her contract and begins working non-contracted with the plan, knowing that the plan’s patients are going to come to the hospital regardless of whether he’s contracted with the payor or not. But now, the physician begins billing the patient for 100 percent of their fee schedule. The health plan will pay what it believes is appropriate, and the balance is owed by the patient
Timeline Providers:
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