Payor Contracting & Credentialing

Payor Contracting & Credentialing

Have you ever had a home project in mind and rather than find a trusted professional to take it on, you decide to tackle it yourself? Even though you’ve never done anything like it before, you make the calculation that a bit of your weekend time is worth foregoing a potentially exorbitant price tag. That makes sense. People do it every day. Let’s add a little twist. You’ve done your homework and have a good idea of the supplies you’ll need for this project, so you head out to your favorite home improvement store without ever making a list. Just before you begin stalking the aisles to check off all the invisible little boxes in your mind, you decide to mix it up even further by putting on a blindfold. After about 20 minutes of running into shopping carts, shelving units, and other people, you give up and go home to nurse your bumps. You then decide to just scrap the project altogether out of frustration over this painful debacle.

This scenario sounds ridiculous because it is. Unfortunately, this is a pretty fair comparison to the way many healthcare providers approach payor contracting and credentialing. All too often, they try to handle one of the most laborious and time-consuming specialties (payor contract negotiations) themselves, quickly become overwhelmed and give up before they really get started. This leads providers to settle for the first reimbursement rates offered by payers in healthcare or just ignore contract re-negotiation completely and keep the old rates. Any provider who goes this route is guaranteed to leave a significant amount of money on the table. The good news is, it doesn’t have to be this way.

Because payor contracting is a tedious process that requires many steps, a few more steps, and then multiple follow-up steps; there are experts in the field to take it on for you. They know how to engage with insurance payors who are often more open to mutually beneficial healthcare reimbursement than you might imagine. Health Professionals Alliance (HPA) has the expertise to undertake all your payor contracting and credentialing negotiations with professionals who’ve worked on both sides of these conversations.

​Who Are We?

Health Professionals Alliance is a national healthcare company that offers a solution-based platform for private Physician and Dental practices to access services, financial, analytics, and consulting expertise. Among our many roles, we have forged a niche in providing proven healthcare credentialing and contract re-negotiation strategies with the goal of finding fair and achievable medical and dental reimbursement rates. HPA has built an impressive coalition of healthcare service specialists and relationships within the industry with a mission to advance private practices. Our goal is to equip your practice with all the tools necessary to stay independent, profitable, and build value while maintaining control over the quality of care your patients depend on.

Health Professionals Alliance exists to make your life easier and payor contract negotiations is a major way we do that every day. Our process has been proven to ensure your practice is able to maximize revenue for years to come

Why Payor Contracting and Credentialing

The American healthcare system has been a complex apparatus with evolving regulatory practices and other frequently moving parts since its earliest days. The Affordable Care Act of 2010, for example, facilitated the biggest shift in healthcare policy for many generations before and these ten years since. That said, there are many frequent adjustments made by insurers that are much smaller but still significant. Because of this consistent revamping of health insurance policies and reimbursement rates, providers are often left ill-equipped to enter into payor negotiation and credentialing on their own. The number of focused hours required for proper payor contracting falls well beyond what any patient-oriented provider could spare. That’s where the expert services of an HPA payor contracting and credentialing specialist become essential.
While payor contracting and credentialing share many similar benefits in terms of maximizing medical or dental insurance reimbursement rates, they are not the same thing. Let’s reflect on their individuality for a moment.

Importance of Data in Contracting Discussions

Data enables us to not only tell a story, but also helps to understand past practice patterns and can be used to predict potential reimbursement with the use of modeling.

Data and analytics can be used to develop your strategy with the payor to support negotiation efforts. Accepting a payor proposal without understanding the financial implication can be potentially detrimental to your practice. Using your data and our experienced contract modeling process, we help you to come to the negotiating table, fully equipped.

Payor Credentialing

Before any new practice or doctor can start billing insurance companies for their services, they must go through a vigorous credentialing and privileging process, not once, but for every single healthcare payor they plan to work with. In order to attract as many new patients as possible, most successful practices partner with 10-plus payors. Considering each one of those requires verification of the provider’s qualifications, expertise and willingness to provide healthcare services to their members, credentialing in healthcare takes months, not days. You may be thinking, “That doesn’t sound so difficult, why would it take so long?” Great question! Every once in a while, you will encounter a payor that does make it relatively simple with virtual options for signing up. Unfortunately, those are few and far between and most reputable payors require a lengthy application process. In these scenarios, it’s best practice to make direct contact with credentialing departments to better understand the individual steps each payor requires. Doing so can vastly expedite credentialing because one false move often results in many months of back and forth to correct it. No matter what, this a slow-rolling process that requires precision and expertise.

Payor Contracting

Once your new practice has gone through the health insurance credentialing process and established a relationship with certain payors, the initial payor contracting phase will begin. Enlisting a professional to take on your new practice contracting makes so much sense because the learning curve is substantial. Each healthcare payor has its own legal jargon and process for negotiating reimbursement rates which means a lot of juggling between insurance companies to understand the fine print. From there, the time will come when you need to engage in contract re-negotiation and this is hands down the most complex job of all. Not only does implementing thorough contract re-negotiation strategies require an immense number of hours but your practice is now fully operational leaving you little time to do more than care for your patients. How much time could you really devote to this process? If the answer is less than full-time for an extended period, you are probably not going to get very far.

Anxious? Don’t be.
No doubt, you are already looking at your calendar to figure out where you can squeeze in a few months for payor contracting or credentialing. Are you freaking out a little bit? Guess what? You don’t have to be. HPA offers expert health insurance contracting and credentialing specialists who already have relationships with payors and will get the job done faster than anyone could do internally. Allow us to explore our methods further.

How HPA Delivers for You

Health Professionals Alliance believes the right kind of experience is key to excellence in everything we do. As mentioned previously, our payor contracting specialists have worked in the field for many years and understand the motivation of insurance payors during contract negotiations because they’ve been in their shoes. That kind of insight is priceless when it means maximizing revenue for your practice. How do we do that? We’re glad you asked.

From the time we begin a project, our intention is to learn more about your contracts than you ever cared to know. That process involves a deep dive into your existing contracts to get familiar with the fine print and the legal language used in each agreement. Then a system for contract management is constructed to organize your medical or dental payor information and notify you when future re-negotiation dates are approaching. Next, we begin analyzing mountains of data to uncover which contracts are working well for your practice and those that need improvement. That’s when it’s time to compose a value proposition so we can set your practice apart from your competitors and begin contract re-negotiation for every under-performing payor agreement.

You may be wondering who could possibly know the value of your practice better than you do? Respectfully, we’d answer the data does and that is where our focus lies. HPA makes a habit of going above and beyond for our clients and part of that is setting you up for realistic outcomes. We analyze every service billed for at least a year to gauge the fairness of your contracts so, if there is room for improvement, we will find it. On the flip side, you may be set on an amount for reimbursement rates for certain services that just aren’t possible depending on your location and/or level of expertise. Our HPA professionals will make sure you have all the information you need right up front to negotiate the best possible outcome.

Our Step-by-Step Approach

As soon as we begin working to advance an effective contract re-negotiation strategy on your behalf, you can count on us to deliver. Our process of negotiating payor contracts goes a little something like this.
Health Professionals Alliance will:

  • Access Contracts – Initially, it’s vital that we get our hands on all the contract documents, including the base agreements and subsequent amendments. Unless you have already embarked on a system for managing contracts, it is likely that this will require contacting payors to access the most current versions of your agreements.
  • Create a Payor Matrix – This process helps to narrow down and organize the core information for all your payors, including the base contract, specific reimbursement policies, timelines for submissions and appeals, fee schedules, and payor contact information. This should become a centralized ‘go-to’ resource for contract management.
  • Rate Payors – Examining all charge and collection data allows us to identify your best and worst payors by a percentage of charges allowed. It’s critical that you filter out which insurance payors routinely deny or underpay claims and where they fall in the ratings. That allows you to make informed choices on which companies you should re-negotiate with and those you should cut loose.
  • Rate Current Procedural Terminology (CPT) Codes – Sometimes CPT codes change so it’s worthwhile to take an inventory of which are working and those that are not. We identify the top billed codes by volume and determine which payors are not adequately covering the cost of providing a service. With that information, we can then negotiate an increase of medical or dental reimbursement for those CPT codes.
  • Verify Termination Deadlines – Payor contracts have clauses that terminate agreements both with and without cause. There are unilateral amendments that can be imposed on an existing contract and will catch you off-guard if you don’t do your due diligence. In these instances, you may or may not receive notification depending on which state your practice operates and you will have a limited timeframe to reject the change. In this case, no news is NOT good news because your silence is equivalent to acceptance.
  • Develop a Schedule for Payor Negotiations – It’s a good idea to maintain realistic goals during the contracting phase and to keep track of when re-negotiation dates are approaching. Whenever possible, we prefer to connect with payors during their ‘off-season’ time because engaging them when they are less busy offers a potential boost in the regular negotiation time-frame.
  • Prepare a Value Proposition – Payors don’t know how special your practice is unless you tell them. The value proposition is a prepared statement that incorporates data to demonstrate why your practice stands out from your competitors. When you can articulate the benefits you provide to your patients, over all others, you move into a stronger position in the negotiation process.
    Gather Data for Contract Modeling – This process allows you to see how much additional money your practice may potentially earn. It involves collecting twelve months of data that includes CPT codes, modifiers, units, and charges so you can model your current contract next to a proposed alternative. Overall, this step gives your organization a comprehensive strategy to counter insurance payor offers and get the healthcare reimbursement rates you deserve.
  • Review Fee Schedules – Your fee schedule requires consistent updates to ensure the CPT codes and descriptions are accurate. This allows you to see clearly where you are getting shortchanged along the way and can more accurately calculate your practice’s collection target to correct that.
  • Confirm all Providers have Current Credentialing and Privileging – Without dedicated staff to keep up with these important details, ongoing credentialing requirements can fall through the cracks. We will make sure your credentialing needs are taken care of.

Our payor contracting and credentialing approach is so thorough because we know how important it is to get it done right the first time. Once we organize all your payor contract information into your own customized matrix, you should never be caught flat-footed with a costly contract auto-renewal again. When future health insurance contract re-negotiations roll around again, HPA will be there to pick up where we left off and make sure your practice is being fairly compensated for the good care you offer your patients.

In Closing

Payor contracting and credentialing is an incredibly precise venture and you are better off to never approach it like a good old-fashioned ‘weekend warrior’ project for your home. It is a long and laborious job to pick apart, analyze, and organize all your insurance payor contracts and HPA’s process is second to none. Our experts will set you up for success so that you never inadvertently miss out on money that should be in your pocket rather than your payors’. When you become a member of the Health Professionals Alliance family, rest easy because your focus can stay where it matters most, on your patients. Why do we do all this? Because we care about the people who provide healthcare services as much as those who need them. That’s why we’re here

Author Bio – Courtney Stevenson; Payor Contracting Specialist

Courtney joined Health Professional Alliance after over a decade of fine-tuning a career dedicated to the healthcare industry. Her payor contracting and credentialing philosophy is one of open communication and straightforward negotiation tactics because she knows what motivates payors to meet her halfway. She has a proven track record of going to the mat for her clients when it’s warranted and for helping them adjust expectations when necessary. Her commitment to providing detailed, comprehensive analysis of your payor contracts is deep seeded and always fruitful. If a path exists for your practice to negotiate the best reimbursement rates among your competitors, Courtney will find it.

Frequently Asked Questions

What is payor contracting?

Payor contracting is the process of reviewing existing contracts with insurance companies to make sure healthcare providers are being fairly compensated. This is a multifaceted endeavor that takes a lot of time to do thoroughly.

What is payor credentialing?

Payor credentialing is the process of applying for the privilege to provide healthcare services within a certain network. This process is payor specific and requires multiple steps and follow up.

What is the difference between contracting and credentialing?

Contracting is the process of negotiating payor contracts for medical or dental reimbursement while credentialing is the process of becoming eligible to bill a network for your healthcare services.

What does ‘credentialing’ mean?

In terms of payor credentialing, the process almost acts as a background check for doctors to gain provider status within a network.

How long does it take to credential a provider?

The payor credentialing process varies between payors so the length of time is unpredictable. The average timeframe falls somewhere between 60-120 days.

How do you negotiate a payor contract?

This is a multi-step process that requires contract review, analysis, modeling, and contact with a particular payor. For more details, review the above section called, “Our Step-by-Step Approach”.

What is the difference between “payor” and “payer?”

According to WikiDiff, “payer” is an alternative form of “payor,” and “payor” is an alternative form of “payer.” As nouns, the difference between payor and payer is that “payor” is used when referring to healthcare/medical insurance–the maker of payment, while “payer” is one who pays, specifically, the person by whom a bill or note has been, or should be, paid.


With all the different definitions available in online searches, this one makes the most sense. 

If “payor” is the supposed, accepted spelling for the healthcare/medical insurance industry, why do some companies still use “payer” to describe their services?

It would be nice if all entities within the healthcare/medical insurance industry would comply and use one term, “payor,” when referring to “payor contracting.” This would help avoid confusing healthcare providers and other consumers looking for “payor contracting” services. We suspect that these service providers are merely trying to capture business by using these terms interchangeably.

Does HPA use “payor” or “payer” to refer to their services?

HPA uses “payor” to describe their “payor contracting” services. This should be the industry standard.

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