Now that you are a new graduate of a school of optometry and have decided where you plan to begin practicing, it is time to make some important decisions that will insure you can start paying back those student loans or invest in your new practice.
Reimbursement today is dependent on which insurance plans you will accept. Time is of the essence and you need to start as soon as you have your license and location to practice. If you plan on examining patients who wish to use their vision and medical insurance, you must be a "provider" with that insurance company. In order to become a "provider," you must be credentialed with that particular insurance. Unfortunately, most medical and vision insurances have their own credentialing processes and procedures. In short, optometry credentialing can be a long and arduous process, ripe with confusion and, of course, frustration.
Below you will find the first steps you need to take to get credentialed with medical and vision insurance plans in three helpful formats: infographic, step-by-step, and a downloadable ebook complete with screenshots!
Starting the insurance credentialing process
Step 1: Set up your business or find a place to practice
The first step in becoming a provider for insurance companies like Medicare, Medicaid, Cigna, Aetna, and others is setting up your business or finding a place to practice.
If setting up a business, your first action is deciding if your business will be a sole proprietorship or a corporation. We recommend that you consult a lawyer or accountant to ensure you make the right decision based on your situation. It is important to be consistent from the beginning to alleviate any headaches in the future.
You can learn more about the different business entities and tax implications in this video interview with Gary Topple, CPA.
Step 2: Apply for your state license
Next, you'll need to apply for and receive your state professional license. Once you have been notified that your license has been approved, be sure to print out a copy that can be sent with your credentialing applications.
Check out this guide on how to get your license in all 50 states, or these provinces for our Canadian audience.
Step 3: Apply for and receive your Individual NPI #
When applying for your NPI number 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.
You will also have to have a practice location to link to on the NPI application. You can get started here
You will have to create a new account and then you can follow the steps for filling out the application.
Step 4: Establish your Tax ID
The next step is to decide how you want to set up your business.
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.
Step 5: If incorporating, apply for Group NPI # after receiving Tax ID #
After receiving your tax ID letter from the IRS (letter 575 or 147C), you can go back to the NPPES web site and apply for your type II NPI number.
Make sure that you list the business name exactly as the IRS letter lists it. Usually the IRS letter won’t list punctuation marks so be sure and don’t use punctuation marks on the NPI application.
After receiving your IRS letter it is also a good time to set up a checking account, listing your name on the checks exactly as on the IRS letter. Many insurance companies either encourage or request that they can make payments to you electronically, and it is important that all documents (IRS letter, NPI name and checking account) match exactly. This will speed up the process.
Step 6: Register for CAQH
CAQH was formerly known as the Universal Provider Datasource. Almost all insurances except Medicare and Medicaid require that you have CAQH and that it is up to date. It is a centralized resource that houses all of a provider's information in one place and it eliminates duplicate paperwork. To complete CAQH, a provider would need all of their education information, their work history, and a few references (varies by state). Depending on the state, you may also need to submit a professional license, DEA certificate, Certificate of Insurance, and/or resume.
Step 7: Determine which vision insurance plans and medical panels to participate in
Talk with your peers for help. Go to local society meetings and find out what others in your area are credentialed for. Call the large employers in your area to see what they have available for their employee health insurances. Check out the websites of other doctors in your area to gather some insight and information on what insurances they are taking.
Step 8: Apply to be a provider for Medicare
Typically the best place to start is here. You cannot proceed with optometry credentialing with several of the medical insurances until your Medicare is approved or at least processing (including Medicaid in some states). The average time it takes to process varies. I have been able to get some providers credentialed in about two weeks, and others it has taken a few months. The average waiting period is 60 to 90 days. Here's a 41-step guide to becoming a Medicare provider
(with screenshots!). This guide
walks you through joining Medicare as an independent contractor.
Credentialing for specific insurance plans
Most insurances have credentialing information on their websites or at least a contact phone number. If a new doctor is going to work for a group, usually someone there can tell them what they need to be credentialed for. I generally recommend you begin applying with medical insurances; however, it varies depending on what kind of environment and patients you will be working with.
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. This has been known to work on several occasions.
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.
Step-by-step credentialing guides
The credentialing process for different insurance plans varies quite a bit. Some plans are relatively simple and others require much more work. The below guides walk you through the process for the most common vision and medical insurance plans.