Open graph Top 5 Mistakes | Top 5 Provider Enrollment Mistakes | STATMedCare Payor and Physician Enrollment and Credentialing

Provider enrollment, or payor enrollment, refers to the process of applying to health insurance networks for inclusion into their provider panels. For commercial insurance panels, this process involves two steps; (1) credentialing and (2) contracting. For government plans, i.e., Medicare, Medicaid, TriCare, etc., this process includes a very complex and involved series of applications.

The first step in the enrollment process is to submit an application, or a request for participation, in writing referred to as a Letter of Interest. The network enrollment process can vary from plan to plan; from a simple application, complicated and lengthy application, use of CAQH, or acceptance of a state approved standardized application.

The network enrollment process can vary from plan to plan; from a simple application, complicated and lengthy application, use of CAQH, or acceptance of a state approved standardized application.

Becoming a provider with commercial and government insurance companies allows you to maintain steady patient referrals and cash flow which is the backbone of any successful practice. The following are five (5) of the most common mistakes that you should avoid which will ensure that your credentialing and enrollment process moves along efficiently and effectively.

1. Incomplete Information: An insurance company needs a thorough picture (current and past) of your organization to determine if you would be a good fit for their provider network. The most common mistake associated with credentialing is a lack of attention to detail. Application errors lead to delays, potential denials, and application rejections. A typical credentialing application will ask for your practice address, phone, fax, contact information, services provided, specialties, copies of your licensure, employment history, average patient profile and any records of past legal troubles regarding your practice.

Omitting information, or making mistakes on any of this data, can lead to delays in your provider credentialing, and it can sometimes be grounds for a denial and application rejection.

What is the solution? All of your provider enrollment applications should go through a rigorous review process to certify accuracy before it is submitted to the insurance network or government payor. Getting it right the first time means you’ll get credentialed faster.

Whether you are compiling this data yourself or working with a provider enrollment and credentialing company, checking your initial enrollment application for completeness is essential.

2. Lack of Follow-Up: Many payors are backlogged with credentialing applications. Make every effort to confirm your application was received and where it is in the process. If something sounds like it doesn’t make sense, question the response. We often hear the following from network representatives; “I have no record of receiving your application” and when presented with evidence of a receipt via a trackable transit confirmation (e.g. fax, overnight delivery with signature confirmation), the answer usually changes to “Oh, it is on my desk.”  Make sure you understand the answer before you accept it.

Follow-up at regular intervals and keep notes, even if the payor tells you to wait 60-90 days to follow up on your application. Regular follow up should be made by phone calls, emailing your contacts and checking web and network directories. Most of the time the payor plans will not call you with updates, request missing information, or inform you of delays.  The only way you will know the status of your application is to follow-up on a regular basis. No one is (or should be) more concerned about your application than you.  Make follow-up a routine and planned event which does not stop until the application is approved and participation is secured.

3. Letting CAQH Lapse: CAQH profiles need to be re-attested, updated and the credentialing contacts kept current. Be proactive when receiving copies of your updated insurance, license or DEA documents and get them uploaded to your CAQH profile with an updated expiration date.  You will avoid delays in the re-credentialing phase if this is part of your routine process. Be clear on who has the responsibility of maintaining your CAQH profile and, as a check-and-balance, make sure the responsible person is copied when there is any activity in your profile.

4. Poor Planning: Many practices get started on the provider enrollment process too late, which can be a matter of success and failure for your practice. At a minimum, you want to give yourself at least 90 days. Realize that you are working on someone else’s timeline – the payor’s. The responsiveness of the payor to your application will be determined by their workload and their motivation to add new providers to their network.  As payors have merged and supersized, a practice’s ability to expedite an application has decreased.

5. Not Understanding the Strict Standards and Guidelines of Government Payors: Provider enrollment in Medicare, Medicaid, Tricare and other government health programs is very different. These programs have standard forms that must be filled out and sent to the appropriate intermediary that handles all of the administrative functions for the program in your jurisdiction. Medicare reviews your application against strict enrollment standards and guidelines. Most providers make the following mistakes with government payors:

  • Using incorrect forms.
  • Using outdated applications.
  • Submitting applications that are incomplete (you must answer all questions and not leave any blanks).
  • Marking incorrect provider type.
  • Not matching the legal business name to IRS records.
  • Submitting applications to the wrong intermediary.
  • Not submitting all required forms and credentials, including your banking information.
  • Using a PO Box as your practice address instead of a verifiable practice location.
  • Not signing your applications in all required fields and not submitting originals (as Medicare and Medicaid require original signatures and not copies or electronic signatures).

Regardless of who is handling your provider enrollment applications, the primary thing to consider and always keep in mind is DO NOT WAIT! The process is very lengthy and you won’t receive “in-network” reimbursements until your contracts are in effect.

Credentialing your providers is labor intensive, with few shortcuts. Practices need to maintain participation in a wide range of plans to not only remain competitive but to facilitate scheduling, coverage, timely payment and the retention of referrals within the organization.

Working with a credentialing and provider enrollment company can help you complete each phase of the provider enrollment process accurately and without delays. These same companies can provide you with assistance with government health programs, with private insurer applications, as well as assist you with CAQH and NPI requirements.

If you would like assistance with credentialing, payor provider enrollment or licensing, please contact us.

Cynthia Young is the former CEO of STAT MedCare, LLC, a U.S.-based, national provider of credentialing, payor enrollment, rate negotiation and other credentialing related services.