Whether you are starting a new solo practice or adding a new physician to an existing large medical group, an efficient process for credentialing and contracting with insurance networks is key to minimizing financial loss when you begin seeing patients. The process known as “Provider Enrollment” includes completing all the necessary paperwork and requests to participate for every insurance network that your practice participates with. Each provider will go through a credentialing process by the payer and once approved by the credentialing committee, a network participation contract will be put in place. The activity between initial submission for participation and acceptance into the insurance provider network leaves lots of room for errors to delay or halt the process. Here are just a few examples of common errors to avoid.
Efficient payers typically have an electronic application process that allows for transmission of large amounts of data for a mass enrollment project, or a web form that allows an individual provider to complete a credentialing application online. However, if you must submit a provider enrollment application via paper, you should first make certain that you have the correct form and version. Considering that it may take 30 days for someone at the insurance company to begin the initial review of your submitted application, the last thing you want to have happen is for them to return the application because an outdated form was submitted.
Do not overlook details requested in an application. Credentialing applications are typically very thorough and require disclosure of a providers education, work history, malpractice claims, and other details. Many provider applications neglect to complete information about a malpractice case only to have their credentialing application with a carrier come to a complete halt when they query the NPDB and see details of an unreported malpractice case. Other information gaps routinely include work gap history, ownership information, hospital privileges, and missing signatures.
Initial submission of the provider enrollment application is only the beginning of the process. The work queues with insurance networks are enormous and there is plenty of potential for your application to get lost or otherwise improperly processed. Be certain to verify that the network has received your enrollment application and then schedule regular follow up phone calls to the provider relations or credentialing department of the plan to make certain that your application is progressing. You will be best served if you make contact with one single individual at each plan who you can contact for information. That is not always possible, but it should always be attempted. Document your phone conversations, get reference numbers from the person you speak with, and schedule your next follow up according to their expected time frame; or a reasonable time frame if they give you vague answers of expected completion.
Although not totally error free, PECOS is the best enrollment tool for enrolling or re-validating your provider enrollment record. The online enrollment system pushes your Medicare provider enrollment application to the appropriate Medicare Administrative Contractor (MAC) for processing. PECOS allows you to monitor your information on file with Medicare and make any changes electronically including esignature for application submissions. There can still be errors and problems with applications because of data transmission between CMS and MACs, but for the most part it is efficient.
Pay close attention to the supporting documents required by each payor that you are enrolling with. This is a common missed item that unnecessarily delays applications. The enrollment applications are lengthy and time consuming, but don’t miss an important document such as board certification, malpractice insurance, or license if it is requested on the application.
Invest in the process
The credentialing process is an ideal process to outsource for any size organization. Small medical practices can benefit greatly from hiring an organization who specializes in healthcare credentialing to handle provider enrollment for a new practice or provider. The potential financial impact of a delayed credentialing process can quickly get in the tens of thousands of dollars for a single provider. Large organizations likewise can achieve benefits by outsourcing credentialing to organizations focused solely on that one tasks. If you decide to go it alone, plan well and be diligent in your follow up with every payor. And, expect to spend 5-10 hours on each application from initial submission to receiving your contract.
nCred is a leading national provider of healthcare credentialing services. nCred has assisted thousands of providers and healthcare organizations throughout the country with the payer provider enrollment process. The successful implementation of leading technologies combined with experienced credentialing staff produce excellent results for nCred clients. Contact us today at (423) 443-4525 or fill out our request for information form to discuss how our services can benefit your organization.