For: Agency Owner · Time: 1–2 hours per practice (one-time decision) · Frequency: New practice onboarding + annual review
Trigger
A new practice asks "which payers should I be in-network with?" — or an existing practice is renewing contracts and you're advising. You're choosing from ~30+ commercial + government payers in their state.
Outcome
A ranked list of 5–15 payers the practice should enroll with, in priority order, with rationale per payer. Drafts created in Applications so credentialing can start. Practice owner agrees with the plan.
Where
- Payer Intelligence Hub — payer rules, fee schedules, denial patterns
- Payers — catalog of available payers
- Reference → State Policies — telehealth rules, Medicaid programs by state
- Applications — create drafts for chosen payers
Steps
- Pull the practice's local payer mix. Open Payer Intel → filter by their state. The platform surfaces "agency-wide" data: of all your existing practices in this state, which payers reimburse best, deny least, and pay fastest. That's your benchmark.
- Score each candidate payer on 4 axes:
- Reimbursement rate vs Medicare — Payer Intel shows your blended rate per payer (collected ÷ billed × adjustment factor). >120% of Medicare = excellent; 90–120% = fine; <90% = re-negotiate or skip.
- Denial rate — your existing denial % with that payer across other practices. <5% = clean; 5–10% = manageable; >10% = ask why before enrolling.
- Days to pay — A/R aging tells you. <30d = fast; 30–60d = normal; >60d = a cash-flow drag.
- Patient mix fit — does this payer's panel actually contain the patients the practice serves? A boutique cash-pay practice doesn't need Medicaid; a community clinic does. Ask the practice.
- Eliminate the no-brainers. Anything that scores poorly on 3 of 4 axes — skip. Anything that scores well on 3 of 4 — include.
- For the murky middle, ask: is the payer GROWING in this state? A payer with shrinking enrollment isn't worth the credentialing time. Use Reference → State Policies for telehealth + Medicaid program changes that affect a payer's footprint.
- Rank by sequence. Some payers should be enrolled FIRST because they're prerequisites or fastest:
- Medicare if applicable — gateway for Medicare Advantage plans later
- State Medicaid if accepting Medicaid patients — typically slowest credentialing, start early
- The local Blue Cross plan — usually biggest commercial share, longest queue
- Optum / United / Aetna / Cigna — common enough to bundle credentialing efforts
- Niche or specialty payers last
- Create draft applications. For each payer in the priority list, Applications → New → status=draft, payer=<picked>. Attach the providers + documents you'll need. This loads the credentialing team's queue.
- Walk the practice through the plan. Share a 1-pager: payers chosen, why, expected go-live dates per payer. Get explicit sign-off — saves arguments later.
Watch-outs
- Effective dates aren't approval dates. A payer can approve credentialing on July 1 but set effective date to June 1. Or vice versa. Don't promise the practice they can bill from approval day until you've checked the contract.
- Some payers require contracting AFTER credentialing. Aetna and Optum often credential first, then send a contract proposal. Don't celebrate at the approval letter — celebrate at the executed contract.
- Closed panels. Some commercial payers close panels for certain specialties in certain ZIPs. Their portal will say "credentialing only" — meaning you can credential but can't bill until panel reopens. Useless. Check the panel status BEFORE submitting.
- Practice change-of-ownership invalidates panel status. If the practice is mid-acquisition, hold credentialing. Otherwise you'll credential the seller and have to redo everything for the buyer.
Related jobs
- Onboard a new client practice — the step before this
- Work an application from intake to credentialed — what your credentialing team does with the drafts you create
Something on this page doesn’t match what you see in the app? Email support@credentik.com and we’ll fix the guide.