Are you about to complete your residency and want to get enrolled with a leading payer? Or do you simply want to expand your patient base by becoming an in-network provider with more insurance carriers?
Regardless of the goal, you must complete credentialing and enrollment to start seeing patients and billing the payer for a steady cash flow.
This guide is a go-to resource for all healthcare practitioners struggling with provider enrollment and credentialing. What does it cover? The key differences between the two processes, key challenges, and best practices. If this interests you, continue reading!
- Provider Credentialing vs. Enrollment: Key Differences
- Provider Enrollment and Credentialing Challenges
- Best Practices for Provider Credentialing and Enrollment
- Partner With MediBillMD to Fast Track Enrollment & Credentialing
Provider Credentialing vs. Enrollment: Key Differences
The table below offers an at-a-glance view of the key differences between enrollment and credentialing:
| Provider Credentialing | Provider Enrollment | |
|---|---|---|
| What Does It Confirm? | Is the provider qualified and competent to practice medicine? | Is the provider authorized to bill for services rendered and receive reimbursement? |
| What Does It Cover? | Its scope is broad and general. That is, it involves a verification of the provider’s entire educational and professional history. | Its scope is business-specific. That is, it ensures a contractual link between the provider, the practice, and the payer. |
| Primary Focus | Primary source verification, education, DEA, and malpractice. | NPI, tax ID (W-9), CAQH profile, and payer contracts. |
| Who Governs It? | State medical boards and accrediting bodies, such as NCQA or the Joint Commission. | Federal programs (Medicare, Medicaid) and private payers, like Aetna, BCBS, etc. |
| Required Data | Education, training, licenses, and malpractice history. | Individual data, along with practice data, is needed for successful enrollment. For example, TIN, practice location, and protocol agreements. |
| When Is It Done? | It is the first step that sets the foundation for all other processes, like privileging and enrollment. | It cannot take place before credentialing. |
| The Outcome | A verified provider file. | An active billing status with a provider ID number. |
What is Provider Credentialing?
Provider credentialing can be defined as the process of verifying a healthcare practitioner’s credentials, such as education, qualifications, training, and medical licenses.
Simply put, it is an integral process that enables healthcare organizations and payers to ensure the provider is certified and eligible to practice medicine.
What is Provider Enrollment?
Enrollment is the process by which healthcare providers join a health insurance network. It is essential to bill the insurance carrier for providing care to their beneficiaries.
Provider Enrollment and Credentialing Challenges
The following are some of the key challenges healthcare providers encounter while trying to get credentialed and enrolled with an insurance company:
1. Data Silo & Administrative Burden
Provider enrollment and credentialing are time-consuming processes. Here are some of the administrative and data-related roadblocks they bring to the table:
Manual Data Entry Errors
Are you completely relying on paper applications or spreadsheets? Beware, because manual data entry leads to high error rates and lost documents.
That’s not all, enrollment and credentialing often require filling out the same 20-page application for different insurance payers. This means that every manual re-entry is prone to a typo in a tax ID or NPI number.
The impact? These data-entry errors can trigger an automatic rejection in the insurance carrier’s digital system, stalling your application.
CAQH Maintenance
Most payers pull data from the CAQH ProView portal. The challenge? You must re-attest your profile every 120 days.
But, given the busy schedule of the providers, the chances of missing the re-attestation window are high.
The outcome? This can immediately freeze all your active payer applications.
Primary Source Verification Delays
Insurance companies validate the information related to medical schools, residency programs, or previous employers by directly contacting them. This process is known as primary source verification.
However, delays in receiving a confirmation from these institutions can further postpone your enrollment and credentialing with the payer.
2. Process & Timeline Delays
By now, you must have a good idea that the enrollment and credentialing process is time-consuming and prone to delays. But let’s further explore this challenge.
The Payer Black Hole
Note that payers typically take 90 to 120 days to process provider enrollment and credentialing applications.
But what makes the entire wait time so difficult? You get zero insight into the process and your application status.
The Linear Delay
As discussed in the comparison table, credentialing must be finalized before enrollment can even begin. This means that even a one-week delay in verifying a medical degree or past employment can push the revenue start date.
3. Financial & Revenue Risks
Your practice’s entire revenue cycle depends on timely enrollment and credentialing. Some of the financial impacts of delays in the process are listed below:
Provider-Not-Enrolled Denials
What happens if you start seeing patients before the effective date of the enrollment? It leads to unbillable claims, and the payment cannot be recovered (permanent denial = lost revenue).
Retroactive Date Issues
Many insurance carriers have rigid policies, and they do not allow backdating of medical claims.
The result? Any care service provided during the application wait time is essentially free care.
Credentialing Lapses
Are you tracking expiration dates for DEA licenses or malpractice insurance? If not, start tracking it because failure to do so can lead to immediate contract termination by insurance payers.
4. Regulatory & Systemic Complexity
There are also some regulatory compliance-related issues you must be familiar with to prevent unnecessary delays.
State-Specific Variations
The enrollment and credentialing requirements for payers vary significantly across states. That is, each state has different licensing timelines and application submission policies that impact how quickly a provider can be loaded into the payer system.
NPI Linkage Failures
Did you know what happens when you incorrectly map a provider’s individual (Type 1) NPI to the organizational (Type 2) NPI or Tax ID? It results in enrollment denials for newly credentialed healthcare practitioners.
Closed Panels
There may be scenarios where some insurance companies simply say no to new providers, claiming their panel is full. You will most likely encounter this situation in saturated markets.
Best Practices for Provider Credentialing and Enrollment
Now that you know the hurdles you can face while trying to get credentialed and enrolled with a payer, it is time to understand the best practices. How will it help? If you implement the effective strategies discussed in this section, you will not encounter a bumpy road. So, here we go:
- Plan to initiate the credentialing process at least 120 days before you want to start seeing patients. This will save you from payer black holes and provider-not-enrolled denials.
- Avoid relying on spreadsheets or searching through scattered hard copies. Instead, create a digital folder to store all primary source documents. This will speed up your enrollment and credentialing application submission process.
- Create a ‘provider packet’ that includes a W-9 form, a detailed CV without unexplained employment gaps, and a list of all past hospital affiliations.
- Set calendar alerts to re-attest CAQH profiles every 120 days.
- Double-check that the practice address and tax ID on the provider’s CAQH ProView match their NPI Type 1 and Type 2 records exactly. Note that even a minor suffix difference can lead to application rejection.
- Verify that the individual’s Type 1 NPI is correctly linked to the group’s Type 2 NPI within the National Plan and Provider Enumeration System (NPPES) registry.
- Why waste time and wait for credentialing to be finished to prepare enrollment applications? Use the time efficiently and have the forms ready to submit once the primary source verification is complete.
- Leverage automated tools to verify licenses and OIG/SAM exclusions monthly, rather than waiting for the biennial re-credentialing cycle.
- Never schedule a patient before receiving a written confirmation of the payer’s effective enrollment date.
- Assign a team member to call all payers weekly to get an update on the application status.
- Maintain a communication log including the date, time, payer representative’s name, and reference number for every follow-up call.
- If a payer claims their panel is closed, immediately submit an appeal highlighting the provider’s unique sub-specialty or the practice’s service to an underserved population.
Partner With MediBillMD to Fast Track Enrollment & Credentialing
With that said, it is time to conclude! The challenges we discussed in this guide may make you feel overwhelmed or uncertain about the enrollment and credentialing process. But, hopefully, if you implement the best practices, you will be able to navigate the intricacies with ease.
In case you do not want to handle this in-house and need professional help, feel free to outsource provider enrollment and credentialing services to a reliable medical billing company, like MediBillMD.
