Getting To Know The Specialty Provider Group

Lesson 1 of 5

Specialty provider groups will have different policies, procedures, credentialing preferences, and billing models. All of these things are important for a clinic to understand before making a final decision. Click through the cards below to learn why each question is important to ask, and how the information learned can help you choose the best provider group.

Some specialty provider groups offer one specialty only (such as Behavioral Health) and others offer a wide variety of specialties (including Behavioral Health).  Some clinics prefer the one stop shop for all their specialty needs, simplifying the contracting, credentialing, referral process and workflow, and other clinics prefer to shop around and find the best price for each specialty.

Ask “What specialties are available through this provider group?”

Provider with Stethoscope

By proxy or full credentialing will make a difference in how fast you can bring a specialist on-board and should be established in advance. If you are billing on behalf of the specialty provider, you will need to bring them into your four walls and will need to credential them at your site.  Some specialty service providers will only utilize credentialing by proxy, while others will accept your wishes for full credentialing.  In addition, the specialty providers will need to be credentialed with the patient’s health plan.

Ask “Does the specialty group have a Credentialing policy or preference? “

Referral guidelines are an important communication tool that specifies the time required for new and follow-up patients, as well as if/when a provider should be in the room during the consult, and finally, the information that is needed prior to the consult (labs, chart notes, etc.). This will be helpful so that you know the exact requirements as they may vary from specialist and specialty. Also tests can be costly (and at times, unavailable) for a portion of your patient population.

Ask “Does the specialty provider group have referral guidelines for each specialty?”

There are several billing models used by  specialty provider groups, and it’s important to discuss these and establish a model thats mutually beneficial in advance. These items will help determine the financial model that best fits your program. Note:  Before you negotiate, you should know how many referrals you think you will have for each specialty and how soon you will be able start.

Ask “Does the provider group contract with your payer(s), bill you by the hour or block of time or patient seen, etc?”

Depending on the specialty services needed, as well as volume and modality for each specialty, rates will vary. Rates for store and forward specialties will typically be lower than live video specialties, and new patient appointments may be more expensive than follow-up appointments. Also, rates may vary according to the volume of patient referrals you anticipate sending to the specialty group. Keep in mind if a specialty group bills by the hour, it is important to know the time required for new and follow-up patients (see the next question). If the specialty group bills by the completed encounter, the rates may be higher than the hourly rate.

Ask “What are the rates for live video and store & forward? Are they the same for adult and pediatric?”