Why should you contract with New York Medicaid?

Providers who would like to provide services to the Medicaid population in New York, need to contract with NYS Medicaid. New York, is one of the states that utilizes the managed care model in Medicaid. This means that the providers need to contract with Managed Care Organizations like Health Maintenance Organizations (HMOs), which are essentially health insurance plans, to provide services to individuals who are enrolled in Medicaid – to learn more about HMOs you can click here.

What are the steps you should take before you start your contracting process?

Before you start your contracting process you should make sure that you are enrolled in the New York State Medicaid program. Most providers need a National Provider ID (NPI) to submit an enrollment application to NYS Medicaid. You can view the provider types that are exempt from the NPI requirement here. 

You can find the enrollment form in this link. Depending on the provider type and the type of enrollment you want, you might need to submit different applications. Although the specifics of the applications may vary slightly, you will be asked to provide certain information about yourself like date of birth, license number, and email address; and your practice like location and contact information. You will also be asked to fill out and submit a Disclosure of Ownership (DOO) form. Once you submit your enrollment application New York State Department of Health will review your application and make a decision.

How to get a contract with an HMO? 

Once you are enrolled in Medicaid, you need to get credentialed with certain HMOs to provide services to their members. To do this, you can contact the HMOs directly to request information on application procedures and requirements or you can get credentialed through an Independent Physicians Association (IPA).

Contracting with HMOs directly

Usually, you will be asked to fill out an application form and provide information about yourself, your degree, and your practice alongside certain documentation. The HMO will then review the application, and decide on your participation with the network. Note that HMOs in New York are not required to accept all providers that meet the minimum qualifications to become a part of the HMO network, thus admittance of a provider into the network is at the discretion of the plans.

• Pros of contracting directly: You can contact the HMO directly for all of your inquiries yourself, without an intermediary.
• Cons of contracting directly: You will have to get credentialed with every plan, and you have to do it yourself. Depending on how many plans you want to get a contract with this might be very time-consuming. After you get credentialed, you will be the primary point of contact for all things related to your contract, rates, quality scores, chart chases, and much more. Since you will be a single provider you will not have increased negotiation power.

Contracting with HMOs through an IPA

The other way to contract with HMOs is through Independent Physicians Associations (IPAs.) Certain IPAs can perform delegated credentialing for the HMOs that they are contracted with, meaning that they can carry out their credentialing process – which aligns with the standards and regulations – to enroll providers participating in their network with HMOs that they are contracted with. 

If you choose to contract with an HMO this way, you will be asked to fill out an application to participate in the IPA. Once the IPA receives your application, they will review it and perform delegated credentialing on behalf of the HMOs. For more information on delegated credentialing, you can click here. While the contracts between the IPAs and HMOs are audited and regulated, certain terms such as but not limited to compensation, claims processing, and quality assurance can be varied. 

• Pros of contracting through an IPA: The IPA will take over the credentialing process and will do the paperwork for you. You will only need to submit one credentialing application and will have the option to get a contract with multiple plans through the IPA. The IPA will also serve as an intermediary between you and the HMO in handling processes like chart chases, quality initiatives, and provider advocacy. The IPA contracts tend to have more competitive rates thanks to the negotiation power the IPA harbors with its large provider network.
• Cons of contracting through an IPA: Since the contract is between the HMO and the IPA, you might need to contact the IPA for certain inquiries like questions on claims processing and appeal status, instead of inquiring directly with the HMO.

---