Celebrate Freedom from Provider Enrollment Issues
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Provider enrollment is a complex process with many details and nuances to be adhered to, checked, verified, submitted, and followed up on. What can a provider do to help reduce the issues and exercise their independence from the piles of paperwork required for enrollment?
A critical distinction should be made to keep our focus on the issues at hand. Provider Credentialing is the process of gathering and authenticating a provider’s license, certifications, professional background, and education history. Provider Enrollment is the process of enrolling a provider with commercial or governmental health insurance plans so that the provider can be reimbursed for services rendered. Credentialling is typically performed by the facility where the provider will be practicing. However, enrollment is up to the billing staff to free them from revenue delays and denials.
As we celebrate Independence Day this July 4th, we’ll take a look at four Provider Enrollment Fireworks to watch as you ensure freedom for your practice. A streamlined payer enrollment process means providers can start seeing patients and billing for services sooner, resulting in a stronger revenue stream earlier in the process.
The most critical piece of any good provider enrollment process is timeliness. Providers must work in concert with their enrollment teams to reduce delays. Payers typically require between 60-120 days to complete provider enrollment. Smaller plans with limited resources may take even longer. Be sure to notify the provider enrollment team promptly of any changes, including: location changes; new locations; new providers; providers exiting the practice; organization structure changes; ownership changes; changes in licenses, certifications, or DEAs; updated board specialty certifications; any changes in group affiliations; and updates to CVs.
Firework Tip – A new provider can easily require three (3) months to fully enroll. Notify the provider enrollment team as soon as possible upon hiring a new provider.
The amount of documentation required for a provider can be overwhelming. Providers beginning the enrollment process must assist the team supporting them and respond timely to inquiries. To begin the process, gather the following: professional license, CV, certifications, malpractice certificate, references, practice ownership details, IRS W-9 form, background checks, bank statements, NPI, EIN, DEA, CAQH information, and a handwritten signature.
Firework Tip – CAQH requires quarterly re-attestations. A provider should always have their CAQH username and password on file.
Payer enrollment is an ongoing process for every provider in each payer network. Payers require their networks to re-enroll or verify credentials every few years to ensure network providers are still eligible to deliver high quality care. Private and public payers do not have standardized processes for payer enrollment. In fact, payer rules and requirements can be quite different and change frequently. Deficiencies in completed paperwork or collection of required documents will cause delays and add inefficiencies to an already lengthy process.
Firework Tip – Keep copies of all completed applications, contracts, credentialing and enrollment letters. These are key to review when verification for accuracy is required.
While the process for provider enrollment may feel as though it takes an army to fight for freedom, all that is needed is a bit of persistence and tenacity. Enrollment is an ongoing process. Once an application is submitted, the work is not finished. It has just begun. Follow up on the status of all applications and inquire if there are unexpected delays.
Firework Tip – Always obtain a reference number when following up. Track these in a log for each application to create a detailed record of the activities required and timelines for each payer. Use this information to streamline your processes.
Bonus Firework Tip – Don’t forget to include all EDI and ERA/ACH enrollments in your provider enrollment process. Make sure providers are not only enrolled but also able to submit claims electronically and receive electronic remittances and payments in return!
The two biggest factors for Provider Enrollment are responsiveness and timeliness. A provider enrollment process is only as good as the information they receive in a timely manner. As America celebrates with fireworks this year, watch your provider enrollment process to see if your results are a colorful display or a cloud of smoke.