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Credentialing and Insurance Specialties

Specialties don’t make you special to insurance companies that is.

One of the most common questions I hear in credentialing after an application is denied is “But I do (blank), and no one else is my area does. Shouldn’t I get credentialing because of this?”

Unfortunately, the answer is often “no,” and it has more to do with the insurance company than types of insurance specialties. The reasons are many and are important for providers to understand in order to better prepare themselves for working with managed care.

The Insurance Company doesn’t need your Insurance Specialities.

Let’s start with the shortest, most brutal explanation: your specialty (or specialties) is not something that they care about. I think the best example of this (and there are many) is Yoga Therapy. Even if it is the most requested form of therapy in an area where you are the only provider within 50 miles, it is not going to get you credentialed.
You may become in network for other reasons besides specialties like this, but it just not a treatment modality that insurance companies are interested in.

Competition

The next reason is that many other providers in your area may have the same specialty as you. The best way to avoid this is to research your competition in the area before you establish your practice and be aware that many specialized clinicians may not feel the need to do marketing.

One key thing to be aware of is that having training or a national certification will always trump experience on a resume when it comes to proving your skills to an insurance company. This is simply because certifications require a known quantity of training, experience and tests. Unfortunately, the quality and effectiveness of the work you did at a certain place is almost impossible to prove.

Location

Finally, insurance companies have their own algorithms and policies to determine how many of which type of provider they need in a geographic area. This is based on the number of members in a given region, so it is very common for insurance companies to perceive no need in their network for what you provide.

Still, your perspective as a working clinician might be that the community is underserved for your specialty, and it is important in these instances to inform the insurance company of the discrepancy between your view and theirs.

In addition, gaining certifications in specialty areas are a great way to define yourself as a clinician and will always make you a more attractive candidate for credentialing. Remember, however, that it is important to do your research into what insurance companies are looking for in your area before committing the resources (both time and money) to getting certified.

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