Payer Provider Enrollment Does Not Have to Be a Waiting Game

By Chastity D. Werner, CMPE, RHIT, NCP, CRCR, Anders Health Care

Provider enrollment with payers can be a cumbersome and time-consuming process for administrators as well as providers. With constant process changes by payers and changes in the reimbursement models, payer enrollment in medical practices is often a task that is put off until it cannot wait any longer. Without credentialing of our providers with our contracted plans, we face the prospects of unbilled services and out-of-network processing that can cause unnecessary financial obligations for our patients. But, why does the process take so long, and does it have to?

Whether you are a single provider practice or a large health system you share many of the same pains:

  • The unknown
  • Compiling and receiving provider documents
  • Capturing provider signatures
  • Following up with payers

There are some easy solutions to these pains that you can implement today to see immediate results.

The Unknown

If you are a smaller practice, this is a common issue. When you don’t perform payer enrollment functions routinely, you can be unfamiliar with requirements and current processes. There are several resources that can assist, and many of the payers have information on their website. When in doubt, you can always call and ask what steps to take and how to take them. There are plenty of other educational webinars on payer websites and by many professional organizations such as National Association Medical Staff Services (NAMSS), with local chapter meetings and educational events.

Compiling and Receiving Provider Documents

Regardless of the size of your practice or hospital this can be one of the most tedious of all the tasks: trying to get all the information you need from the providers. Why wait? You can access their CAQH file and download all of their documents yourself. As long as the provider has kept their CAQH file updated, this is the most direct way to obtain what you need. This process is also more convenient for the provider. There are some wonderful software platforms available that will communicate and streamline information from CAQH as well.

Unfortunately, if your provider is a new provider without a CAQH profile, the process will not be as easy. But perhaps you can set up a secure portal which will allow the provider to scan and send the information to you electronically. The more convenient the process, the more likely it will get completed.

Capturing Provider Signatures

If you are a large health system this seems to be one of the major issues. Capturing the needed signatures and receiving them in a timely manner can be burdensome to say the least. One of the most effective solutions we have found is having the applications ready for signature and sent with the employment agreement. Educating the provider on the process and importance of timely turnaround is key. Credentialing equals revenue to providers, especially if the provider’s compensation is focused on their collections. Most importantly, mark the areas and provide instructions and checklists when possible. Depending on your organization’s process, you can also have the provider sign contracts electronically.  This is a convenient solution if the provider is located in another state or area.

Following up with Payers

This can be one of the hardest for most to accomplish because it requires disciplined follow-up over a period of time. Even though it is not the most complicated, it is time-consuming. Create a tool such as a ‘Payer Status Tool’. The Payer Status Tool will allow you to document notes, set-up follow-up dates and record contacts. There are several software programs that assist with this process.

Even with these tips, do you still feel like this is a daunting task? When all else fails, outsource it. Partner with a vendor with expertise and a proven track record to expedite and manage the process. It can be cost effective while speeding up the credentialing process and taking the burden from your shoulders.

Questions on the credentialing process or need some ideas? Send me an email at cwerner@anderscpa.com.