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Provider Enrollment: Where Do I Begin?

Provider Enrollment What an overwhelming process!  So much data and documentation are required.  It can be very tedious and quite exhausting.  And now you have a provider wishing to contract with a new insurance payer, but where does one begin?  Learn best practices for initiating the process of Provider Enrollment in an organized and efficient manner.   

In a few words, Provider Enrollment is the process of registering a healthcare provider with an Insurance Payer so that the Healthcare Provider may bill and receive reimbursement for services rendered.  The key to success is simplifying this otherwise complicated task. 

The process begins with credentialing your provider or obtaining and verifying their professional documentation.  The goal is to verify that your provider is who they say they are, and that they are qualified to do what they say they are qualified to do.  The best way to start is by collecting the following information with the supporting documents, including but not limited to your provider's personal demographics. 

  • Professional Licenses and Certificates
  • DEA and/or CSR 
  • Education/Training, including Graduate and Under-Graduate; Fellowship, Residency, and Internship
  • Board Certification
  • Work History - gaps in employment greater than 3 months require a written explanation from the provider
  • Professional Liability Policy
  • Hospital Privileging or Admitting Arrangement 

When you finally have all the necessary information collected, the next best practice is to register your provider and health center with CAQH, the Council for Affordable Quality Healthcare.  CAQH is a non-profit organization that collects and stores provider and practice information, which is utilized by Medicare and Medicaid and by many private carriers.  The information stored in your CAQH account is secure and confidential.  Routinely ensuring that your practice and provider info is up to date in your CAQH profile will certainly ease the enrollment process moving forward, along with streamlining the revalidation process with your Payers.  Having the previously listed documentation handy will expedite the CAQH registration process. 

At last, you are ready to reach out to the respective Payer.  It is beneficial to contact the Payer to verify their enrollment specifics before you begin the application process.  Knowing what the Payer expects upfront is a time saving, back and forth reducing, double- and triple-work limiting benefit.  Time is of the essence when it comes to Provider Enrollment: If your provider cannot bill for services rendered, then he does not get paid for those services.   

Here is a comprehensive list of topics to ask or review with the Payer:  

  • Process Overview - Find out what the Payer's process of enrollment is; the various steps, stages and phases, checks and balances.  
  • Which Forms - Confirm which forms are required by the Payer in order to complete the application process. 
  • Requirements (data and documents) - If possible, obtain from the Payer a list of required data and documents; so, you’ll know what to gather from your provider. 
  • Processing Timeframe (so you'll know and can better manage your provider's expectations) - What is the Payer's turnaround time after the application is submitted.  How long does the Payer anticipate it will take to receive a "yay or nay."  
  • Submission Method (paper versus electronic; wet/ink signature vs electronic signature) - Confirm the Payers preferred method of transmission; paper or electronic.  Also, confirm if the Payer requires a wet or ink signature.  This is very important, as we don't want to slow the process due to a "missing" signature. 

Go forth and apply but remember to "keep your eye on the prize!"   Payer Enrollment is fundamental to the success of your health center's revenue.  For this reason, the application process requires constant attention and follow-up.  Typically, it takes between 60 and 180 days to obtain acceptance (or denial); of course, turn-around times vary per Insurance Payer.  Develop a routine for touching base with your Payer Representative, so that you can monitor your provider's enrollment progress all the way to acceptance; besides, we don't want the Payer to forget about you or let your application fall through the cracks.  

Because Credentialing and Payer Enrollment is such a tedious and time-consuming task, and compliance is critical to conform with state and federal regulations, outsourcing this chore is definitely something to consider!  Visualutions is committed to doing the work and investing the time so you don't have to. 

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