April 30, 2025
How to Navigate Credentialing Hurdles
- by Dawne Wood, Director of Credentialing Services
To treat a patient using “in-network” benefits, providers/practices need to be credentialed and contracted as participating “in-network providers” with the patient’s insurance company. When an insurance company feels that they have reached an adequate number of providers for a particular specialty in a geographic area, the payor can suspend writing new contracts for new providers/groups for that specialty in that area. This results in what is known as Closed Panels, and they are more commonly found in larger cities where numerous physicians of the same specialty practice within blocks of each other.
How to Navigate Closed Panels
The good news is that with a little effort, many payors will grant an exception when they have closed panels. Some insurance companies will tell you to call back in 6-12 months to see if the panel has reopened; however, most will accept some sort of appeal letter allowing the practitioner to state their case for why an exception should be made. These appeal letters are not guaranteed to be accepted, but there are a few key factors that could increase your chances:
- Currently, there is no national standard that insurance companies use to determine whether their networks are adequate. Evaluation of health plan networks is based on the payor’s provider directory, which is often incorrect or outdated. When doctors close an office or retire, they often forget to inform insurance payors of their inactive status, which prevents another doctor from taking over that spot in the network. The insurance company isn’t likely to know and isn’t likely to tell you. A review of the payor’s provider directory can provide information on which providers are listed as participating providers for each payor by specialty. If this information is not accurate, there is reason to dispute the panel closure and utilize that information to gain access to the network’s panels.
- Differentiating your practice is key. Describing detailed specifics, such as certifications, and/or specialized equipment being used in the practice, specific provider experience, and even awards, could set the provider/practice apart and open a panel spot. In addition, factors as simple as having normal operating hours outside of normal operating hours could prove to be valuable criteria to consider.
- “Any Willing Provider” laws allow physicians to contract with insurance companies to participate as in-network doctors without discrimination.
How are States Handling the Limited Access?
Because many insurance companies limit access to their networks for new physicians, new practices are limited in their ability to establish a practice and provide patient care. However, thirty-five states have adopted “any willing provider” laws, which allow physicians/pharmacies to contract with insurance companies despite payor panel decisions. Of those 35 states, 12 have laws established regarding physician contracts specifically.
Reach out to DoctorsManagement for Assistance
If you need assistance navigating closed panels, DoctorsManagement offers a wide range of credentialing and payor contracting services.
To find out more about how Any Willing Provider laws or Network Adequacy requirements, please see the following links:
- https://healthcare.uslegal.com/managed-care-and-hmos/state-laws/
- https://vbc-advisory.com/2023/06/29/35-states-with-any-willing-provider-laws/
