FAQs

On our Frequently Asked Questions page, you can find the most common questions answered for the following categories: 

  • Enrollment & Credentialing Questions

  • CAQH Questions

  • Medicare Enrollment Questions

  • Start-Up Including Marketing Questions

  • Marketing & Website Questions

  • Revenue Cycle Management Questions- Coming soon

FAQs- Enrollment & Credentialing Process

Provider credentialing verifies a healthcare provider’s qualifications and ensures compliance with regulatory standards, enhancing patient safety and care quality.

Source: physicianpracticespecialists.com/the-difference-between-payor-enrollment-and-provider-credentialing-in-healthcare/

Provider enrollment involves registering with insurance networks to receive reimbursement, whereas credentialing verifies a provider’s qualifications.

Source: physicianpracticespecialists.com/the-difference-between-payor-enrollment-and-provider-credentialing-in-healthcare/

The process typically takes 60-120 days, depending on the provider’s information completeness and the insurance company’s requirements.

Source: physicianpracticespecialists.com/nationwide-insurance-enrollment-credentialing-services/

Required documents include licenses, DEA certificates, malpractice insurance, and proof of education and training.


Source: physicianpracticespecialists.com/understanding-insurance-credentialing-process/

Contact the insurance network or healthcare organization where the application was submitted for status updates.  Many payers have moved to an automated IVR system that will require you to have provide your application reference number.

 

Source: physicianpracticespecialists.com/commonly-asked-questions-about-credentialing-services/

Incomplete applications, discrepancies in credentials, and negative professional history are common reasons for denials.


Source: physicianpracticespecialists.com/top-15-medical-credentialing-provider-enrollment-questions-answered/

Review the denial reasons, correct issues, and resubmit the application to ensure compliance and approval.


Source: physicianpracticespecialists.com/credentialing/payer-panel-closures-and-the-rising-costs-of-healthcare/

Hospital credentialing ensures providers have necessary privileges to admit patients and meet hospital standards.


Source: physicianpracticespecialists.com/credentialing-checklist/

Malpractice insurance protects against claims and is required by most insurance companies during the credentialing process.


Source: physicianpracticespecialists.com/credentialing-checklist/

They streamline the process, reduce administrative burdens, and ensure compliance with industry standards.


Source: physicianpracticespecialists.com/credentialing-services-that-can-help-your-physician-practice/

They ensure adherence to regulations and maintain a professional standing, reducing legal risks and enhancing credibility.


Source: physicianpracticespecialists.com/credentialing-services-that-can-help-your-physician-practice/

Challenges include complex requirements, lengthy processes, and frequent follow-ups to ensure timely approvals.


Source: physicianpracticespecialists.com/understanding-insurance-credentialing-process/

They manage documentation, submissions, and follow-ups efficiently, reducing administrative burdens on providers.

Source: physicianpracticespecialists.com/enhancing-enrollment-for-streamlined-finances/

Proper credentialing prevents billing denials and ensures timely reimbursements, optimizing cash flow.


Source: physicianpracticespecialists.com/enhancing-enrollment-for-streamlined-finances/

Ensure all locations meet credentialing requirements and update CAQH profiles accordingly.


Source: physicianpracticespecialists.com/download-credentialing-checklist/

It includes submitting applications, following up, and negotiating contracts with insurance companies.


Source: physicianpracticespecialists.com/understanding-insurance-credentialing-process/

FAQs- CAQH Registration & Process

CAQH is a nonprofit organization offering a centralized credentialing database used by many insurance networks.


Source: https://physicianpracticespecialists.com/credentialing/what-is-caqh-and-why-matters-to-your-practice/

Register by creating a profile on the CAQH ProView platform and submitting necessary documentation.


Source: https://physicianpracticespecialists.com/services/caqh-registration/

Required information includes personal details, practice information, licenses, certifications, and professional history.


Source: https://physicianpracticespecialists.com/services/caqh-credentialing-services/

CAQH allows providers to submit a single credentialing application to multiple insurance networks.


Source: https://physicianpracticespecialists.com/services/caqh-registration/

Documents include professional licenses, DEA certificates, malpractice insurance, and education and training records.


Source: https://physicianpracticespecialists.com/credentialing-checklist/

Providers should update their CAQH profile at least quarterly or whenever there are significant changes.


Source: https://physicianpracticespecialists.com/credentialing/commonly-asked-questions-about-credentialing-services/

Authorizing access allows insurers to verify your credentials and expedite the credentialing process.
Source: https://physicianpracticespecialists.com/services/caqh-registration/

Log into your CAQH ProView account to track the status of your application.

Source: CAQH ProView – Sign In

Incomplete applications will delay the credentialing process; ensure all information is accurate and complete before submission.


Source: https://physicianpracticespecialists.com/credentialing/what-is-caqh-and-why-matters-to-your-practice/

Re-attest by logging into CAQH ProView and confirming that your information is accurate and up-to-date.


Source: CAQH ProView Provider User Guide

CAQH simplifies the credentialing process by providing a centralized database for submitting credentials to multiple insurers.


Source: https://physicianpracticespecialists.com/credentialing/what-is-caqh-and-why-matters-to-your-practice/

Yes, CAQH can be used for credentialing both individual providers and group practices.  The group practice profile will show you all providers linked to your organization but you must be set up as an administrator.

Log into CAQH ProView and make the necessary updates to your profile information.

Source: Updating CAQH Profile

CAQH ProView is an online database that allows healthcare providers to submit and maintain their credentialing information.

CAQH services are generally free for healthcare providers, though some insurers may have their own fees.

Source: Do you pay for CAQH credentialing?

FAQs- Start-Up Process Questions

Steps include creating a business plan, obtaining financing, choosing a location and credentialing/contracting with payers.


Source: physicianpracticespecialists.com/start-up-checklist/

Consider factors such as patient demographics, competition, and accessibility.

Source: 10 Key metrics for selecting the best practice location

Licenses and permits vary by state but typically include a medical license, business license, and any specialty-specific certifications.

Source: Practice Outline & Process

Options include bank loans, private investors, and small business grants.


Source: physicianpracticespecialists.com/start-up-checklist/

A business plan should include an executive summary, market analysis, organization structure, services offered, marketing plan, and financial projections.


Source: Download free proforma

Consider hiring qualified medical and administrative staff, ensuring they meet state and federal requirements.  It’s important when starting your practice that you do not over hire, but hire based on the actual needs of the organization.

Source: Staffing Needs for New Practice

Equipment includes medical devices, office furniture, computers, and medical supplies.

Source: Medical Supplies for new practice

Implement an electronic health record (EHR) system and establish relationships with insurance companies.

Source: Insurance Credentialing & EHR

Use online marketing, local advertising, and community outreach to attract patients.

Source: Top 83 ways to attract new patients

Build a patient base through referrals, marketing efforts, and community involvement.

Source: How to attract new patients

Considerations include business structure, compliance with healthcare laws, and malpractice insurance.

Source: Download Free Start-up Checklist

Use accounting software and possibly hire a financial advisor to manage income, expenses, and taxes.  When starting, it’s best to hire a bookkeeping service and accountant.  Most accountants use quickbooks which will be easy for your staff to take advantage of.

Components include securing financing, obtaining licenses, hiring staff, and setting up billing systems.

Source:Lean Start-Up Method for New Practices

Consider factors such as ease of use, compatibility with other systems, and cost.  There are many specialized EHRs that may serve your practice better than a general EHR.

Source: EHR Consulting Services

Challenges include financing, regulatory compliance, and attracting patients.  The biggest challenge in 2024 is how to effectively utilize technology and lower reimbursement rates for new practices.

Source: 12 Keys to New Practice Success

 

A consultant can provide expert guidance on navigating the complexities of starting a new medical practice.  There are numerous pitfalls that ensnare new medical practices and experienced consultants are a great way to avoid them.

Source:10 Mistakes to Avoid when Starting a Medical Practice

 

Necessary coverage includes malpractice insurance, general liability, and property insurance.  Develop clear policies and procedures for staff to follow to ensure smooth operations and to mitigate risk.

Source:10 Mistakes to Avoid when Starting a Medical Practice

 

FAQs- Medicare Enrollment

It is the process of registering with CMS to become an approved Medicare provider which will allow you to see and get paid for seeing Medicare members.

Source: Medicare Provider Enrollment

 

Requirements include a valid state license, meeting education and training standards, and having malpractice insurance.

Source: PECOS Medicare Requirements

Submit the application through the CMS website or your regional Medicare Administrative Contractor (MAC).  You can submit via paper or via the preferred method of PECOS.


Source: PECOS Enrollment

Required documents include proof of licensure, malpractice insurance, and education credentials.

The process typically takes several weeks to a few months, depending on the completeness of the application.  PECOS is about 50% faster than submitting paper applications.

Source: Medicare Provider Enrollment Tips

Each region has a unique fee schedule through the MAC.  The applicable fee can be determined by using the Medicare Fee Schedule tool.  Use the below link for the training on the Medicare fee schedule lookup tool.

Source: Medicare Fee Schedule Lookup

In many cases, Medicare will approve your application with the requested effective date so long as it wasn’t submitted too soon.  There are specific rules around submitting your application which is covered in our below article.

Source: Medicare Retroactive Billing

Yes, you can appeal a denial by following the CMS appeal process.

Common reasons include incomplete applications, missing documentation, and not meeting eligibility requirements.

Professional services can help ensure accurate application submission, track application status, and address any issues.

Source: Medicare Enrollment Services

MACs process Medicare enrollment applications and manage provider relationships in their designated regions.

Yes, the Medicare DMEPOS enrollment process is unique and is submitted to a different MAC.

Source: DMEPOS Application Essentials | Physician Practice Specialists

FAQs- Start-Up Process Questions

Steps include creating a business plan, obtaining financing, choosing a location and credentialing/contracting with payers.


Source: physicianpracticespecialists.com/start-up-checklist/

Consider factors such as patient demographics, competition, and accessibility.

Source: 10 Key metrics for selecting the best practice location

Licenses and permits vary by state but typically include a medical license, business license, and any specialty-specific certifications.

Source: Practice Outline & Process

Options include bank loans, private investors, and small business grants.


Source: physicianpracticespecialists.com/start-up-checklist/

A business plan should include an executive summary, market analysis, organization structure, services offered, marketing plan, and financial projections.


Source: Download free proforma

Consider hiring qualified medical and administrative staff, ensuring they meet state and federal requirements.  It’s important when starting your practice that you do not over hire, but hire based on the actual needs of the organization.

Source: Staffing Needs for New Practice

Equipment includes medical devices, office furniture, computers, and medical supplies.

Source: Medical Supplies for new practice

Implement an electronic health record (EHR) system and establish relationships with insurance companies.

Source: Insurance Credentialing & EHR

Use online marketing, local advertising, and community outreach to attract patients.

Source: Top 83 ways to attract new patients

Build a patient base through referrals, marketing efforts, and community involvement.

Source: How to attract new patients

Considerations include business structure, compliance with healthcare laws, and malpractice insurance.

Source: Download Free Start-up Checklist

Use accounting software and possibly hire a financial advisor to manage income, expenses, and taxes.  When starting, it’s best to hire a bookkeeping service and accountant.  Most accountants use quickbooks which will be easy for your staff to take advantage of.

Components include securing financing, obtaining licenses, hiring staff, and setting up billing systems.

Source:Lean Start-Up Method for New Practices

Consider factors such as ease of use, compatibility with other systems, and cost.  There are many specialized EHRs that may serve your practice better than a general EHR.

Source: EHR Consulting Services

Challenges include financing, regulatory compliance, and attracting patients.  The biggest challenge in 2024 is how to effectively utilize technology and lower reimbursement rates for new practices.

Source: 12 Keys to New Practice Success

 

A consultant can provide expert guidance on navigating the complexities of starting a new medical practice.  There are numerous pitfalls that ensnare new medical practices and experienced consultants are a great way to avoid them.

Source:10 Mistakes to Avoid when Starting a Medical Practice

 

Necessary coverage includes malpractice insurance, general liability, and property insurance.  Develop clear policies and procedures for staff to follow to ensure smooth operations and to mitigate risk.

Source:10 Mistakes to Avoid when Starting a Medical Practice