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Six Credentialing Tips for New PT Owners

This is part one in a two-part series.  This article will be reflective of a new owner fresh out of school and starting their own clinic. Stay tuned to part two, which will cover credentialing tips for an existing organization that purchases an existing clinic.

Let’s assume the appropriate business prep work has occurred and you have found an ideal location to open your PT business. It has very little competition from other existing outpatient clinics in the area and maybe you’ve even taken the added step and called a few commercial payers to see if their panel was open or full for your geographical region. Because, let’s face it, outpatient therapy is a growing community and sometimes there are many clinics in a small region – and that spells out-of-network for you.

When a region is full for a particular commercial payer, they will tell you so (panel rejection) and ask you to keep calling back, roughly every month.  Essentially you are waiting for another clinic to close its doors so your clinic can takes its place.

Tips to Consider

So, what all should you consider when you’re a new PT opening a new practice? Take a look at these six tips below to help you get started on the right foot.

  • Will you be a solo practitioner or are you considering a group practice? Maybe this is an easy question to answer, but if you are unsure and think, “Hey, I’ll start out as a solo practitioner and if my business flourishes, then I will become a group practice,” my advice is to start now as a group practice.  It doesn’t hurt anything for you to be recognized as a group practice even if you are the only one treating patients.  Completing the credentialing paperwork as a solo practitioner and then deciding you want to be a group will require you to redo your contract profile. Thus, possibly holding up payments or causing you more credentialing paperwork than you have time for.  Apply here for a group NPI as an Organization
  • Group or Organization basic information. If your office building is under construction, please try to resist the urge to use your home address on the insurance credentialing forms in place of your office’s physical address. This will add rework in the future which you may or may not remember to do. You would think completing address changes with the Payer would be a simple task, but they aren’t. You can expect anywhere from 2-4 weeks and Medicare Railroad takes 45 business days.
  • Adding a new therapist/provider to your practice. Whether the therapist is right out of school or transitioning over from another clinic, ideally you might want to consider starting the credentialing paperwork before they’re scheduled to start at your clinic.
    • If the therapist is already credentialed with Payers, then it is only a matter of notifying the Payer this provider needs to be added to your group. The process can be as simple as a one-page form taking a matter of a few weeks to process. Boom, done!
    • If the therapist is fresh out of school then allow 30-90 days minimum to be qualified to treat without a cosigner. In some cases, the provider wouldn’t be able to treat a patient at all, unless authorized by the Payer. Remember, every Payer is different with different guidelines.  The new therapist could also be considered out of network until the credentialing has been finalized.  Medicare will allow you to retroactively bill your claims from when you first started your credentialing process, but many other Payers do not follow this rule.  Don’t assume and always ask.
  • Complete a CAQH profile. What is CAQH?  It’s a Universal provider database.  It acts just like credentialing software.  It holds all your pertinent profile information. Certain commercial Payers will require access to this information in lieu of filling out paperwork.  And it’s easy to use.
  • Credentialing delays in January. Every January, Payers go through an open enrollment for new patient membership and company’s updating their group policies. The Provider Enrollment department will be pulled over to help with any backlogs. As a result, your credentialing process will be delayed. Something to consider.
  • Medicare, Medicare Managed Care and Medicare Railroad. Expect a site visit from Medicare as part of the credentialing process. Before you can enroll with the Medicare managed plans you will need to have received your Medicare group PTAN (provider number).  You will need to go directly to those Payers websites to complete any further credentialing or registration.  Enrolling for Medicare Railroad is found on the Palmetto GBA website.  Once completed, you will be assigned a separate individual and group PTAN that is separate from Medicare’s PTAN.

Looking for more information on practice ownership? Check out APTA’s site for more support on owning a practice.

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