A closed insurance panel means an insurer is no longer accepting new providers into its network for a particular specialty or area. Providers denied credentialing can accept the decision and operate out of network or appeal for in-network status. When deciding how to proceed, practices should consider the financial impact of out-of-network billing and whether their qualifications, services, availability, or local patient needs support a strong appeal.
Insurance companies can limit the number of providers they accept into their networks, particularly when they determine that they already have enough providers within a certain specialty or geographic area. When this happens, the insurer may close its panel and deny new credentialing requests.
For medical providers, a closed insurance panel doesn’t necessarily mean the end of the road. Depending on the circumstances, you may choose to accept the decision and operate as an out-of-network provider or appeal the denial and make a case for joining the insurer’s network. Understanding both options can help you determine the best path forward for your practice.
When to Accept the Closed Panel Decision
Oftentimes insurance companies say that the closed panel is temporary, and they advise providers to reapply in 3, 6 or 12 months. However, insurers are under no obligation to open panels, and they may credential select providers while denying others.
If denied in-network status, providers may opt to see patients and submit bills to insurance companies as an out-of-network provider. While sometimes confusing and troublesome for patients, this may be the best option for providers.
How insurance companies handle out-of-network claims varies. The plan that patients have determines how much insurance companies pay for out-of-network care. Determining factors include:
- Does the patient have a high deductible plan?
- Does the patient have out-of-network coverage? The patient’s plan must have out-of-network coverage to avoid patient responsibility for the entire claim
- Does the patient’s plan have a separate, higher deductible for the out-of-network benefit?
- What method does the plan use to set the “recognized” or “allowed” reimbursement amount?
The insurance company may base the allowed amount on:
- A percentage of their current Community-based fee schedule for participating providers
- Other types of rate schedules
Physician practices should work closely with their medical billing partners to determine the financial impact of the decision and how to educate patients about this billing process.
When to Appeal the Closed Panel Decision
Providers don’t have to take “no” for an answer. To craft a successful appeal, providers should
- Direct the appeal to the correct individual
- Make a compelling and fact-based case for in-network status (e.g., do you have special training or certifications not typical for your specialty that may differentiate you from your peers?)
It’s critical to send the appeal package to the decision-maker. Typically, the appeal should be directed to the Provider Representative for credentialing, usually assigned by county. The appeal should be both emailed and mailed, return receipt requested, to document and ensure delivery. The person responsible for credentialing should always follow-up with a phone call. A copy of the appeal package may also be sent to the Regional Manager or someone else in the corporate office, if necessary.
A successful appeal package should include:
- The provider’s certifications and any special training
- Special equipment, diagnostic tools or procedures that are offered and otherwise unavailable to patients in the provider’s coverage area
- Evening and weekend hours, if applicable
- Patient-to-specialist ratio for the provider’s area and any other data highlighting physician shortages for the coverage area
- Other physicians on the panel who refer to the provider
- A list of physicians who are not able to refer patients to the provider due to his/her out-of-network status
- Any other facts, data and considerations to strengthen the appeal
Faced with a credentialing denial due to a closed panel, providers have options. Those responsible for credentialing—typically offered as a service of physician practice management company—should be well-versed in compiling and submitting effective closed panel appeal packages.
Accepting or Appealing Closed-Panel Decision FAQs
1. How long does it take for an insurance company to respond to a closed panel appeal?
There is no standard timeline for receiving a decision on a closed panel appeal. Response times can vary by insurance company and may depend on the provider’s specialty, location, and the insurer’s credentialing process. Practices should follow up regularly after submitting an appeal and keep records of correspondence with the insurer throughout the process.
2. Can a provider reapply if a closed panel appeal is denied?
Yes. A denied appeal does not necessarily prevent a provider from applying again in the future. Insurance companies may reopen panels as their networks and patient needs change, so practices should periodically check the panel’s status and follow any guidance the insurer provides about when to reapply.
3. Can a closed insurance panel reopen?
Yes. An insurance company may reopen a closed panel when it determines that additional providers are needed within a particular specialty or geographic area. Changes in patient demand, provider availability, or the insurer’s network needs can all affect whether additional providers are accepted. Because panel status can change, practices that want to join a particular network should continue monitoring its availability even after an initial denial.
A Closed Panel Doesn’t Have to Be the Final Answer
A closed insurance panel can create challenges for your practice, but a credentialing denial doesn’t always mean you have to accept out-of-network status. Understanding the financial impact of remaining out of network and whether you have a strong case for an appeal can help you determine the best path forward.
If you decide to appeal, a well-supported case that highlights your qualifications, services, availability, and the needs of patients in your area can strengthen your request for in-network status.
