Provider Enrollment, The Process

Provider enrollment...What is it and How is it accomplished? To get
an individual healthcare provider enrolled as member of a public
and/or commercial insurance entities' (payor) network require that
they undergo what's called a credentialing and contracting process.
What this essentially entails is two distinct but related activities:
the submission and verification of the providers Curriculum Vitae and
the offer, negotiation and signing of a formal agreement outlining the
terms of business. Each insurance entity has its own process,
procedures and information requirements that a healthcare provider
must follow and submit to successfully enroll in a payor's network
While not uniform by any means, there are general "groups" of activity
common to all.The first phase is the Introduction. This notifies the
payor that the provider is interested in joining their network. It
usually begins with a phone call to the payor network development
office to ascertain exactly what the process is, what information and
applications are required, the time frames involved completing the
process and to start the paperwork flow.Next follows the credentialing
phase., the heavy lifting. Understandably, payors want to know,
literally, everything there is to know about those who join their
networks. Typically, the types of information required are personal
information, employment history, educational background, practice
information and whether or not the provider has encounter any legal or
license issues (read that law suits or revocations). Once the
information has been accumulated and forwarded, it's subjected to a
verification process conducted by the payor or their representative.
The intensity of verification process ranges from all encompassing too
a cursory glance to insure that all the application blanks have been
filled in.Assuming that everything checks out and the payor decided to
extend an enrollment offer to the provider, the final phase of
provider enrollment, the contracting phase commences. The payor sends
the contract along with the reimbursement rates offered. The provider
needs to carefully review each. This is their only opportunity to
request any changes or alterations, at least during the initial term
of the contract. Contrary to what many believe, there is room for
negotiations. It's not necessary to accept the contract without
question. Now admittedly the provider is not in the strongest of
bargaining positions but as the old saying goes... you don't ask you
don't get. Be aware that if they do agree to modify the contract or
rates, it usually goes through an additional approval process that
adds more time to the project.I may have given the impression that
these events are linear. It ain't necessarily so. Many firms request
that you submit a signed contract along with the credentialing
application. I suppose it may save a bit of time in the long run but
if there are contract modifications, approvals will be required which
will delay the initial application submit.What about timing? The
single answer to that question "too long". Forgetting about the
provider's information accumulation process on the front end of the
process, you should figure on a minimum of 60 days and a maximum of 8
months from beginning to end. You can have some influence on this time
frame but it requires constant, ongoing follow-up and contact with the
payor every step along the way.Provider enrollment is not for the
faint of heart. It requires strict attention to details along with
follow-up, follow-up, follow-up. Assigning this project to an
individual with little or no knowledge about the subject or suffers
from impatiences or a short attention span is a recipe for disaster.
Disaster in the form of a long drawn out process and lost revenue.
Understandably many health care providers don't have the time to
adequately manage this process, so if you're electing to have someone
else to undertake this project on your behalf, chose your
representative carefully. Be sure that all the information required
during the credentialing process is accumulated ahead of time or is at
least readily available. Finally allow your self or your
representative ample amount of time to effectively accomplish the
job.