For most major healthcare providers, the payor enrollment process can be a nightmare of forms, forms, and more forms – not to mention jumping through a few hoops. Inevitably, you just want to quickly get a practitioner enrolled into a payor program and start receiving payments for their services.
Why not skip the lengthy wait for reimbursement by optimizing your payor enrollment process? We’ve organized an in-depth checklist for three major payor enrollment components to help you develop a more efficient process:
What is Provider Enrollment? Download symplr's Payor Enrollment Data Sheet to learn more.
Step 1: Determine Which Plans to Enroll
This process of applying to health insurance plans and various networks is what payor enrollment is all about. You’ll determine which plans you will be included in for provider billing and payment for services rendered. After they are credentialed and granted privileges, each practitioner must be enrolled. Here are the three main enrollment types:
- Federal and State Programs (Medicare and Medicaid)
- Private and Commercial Programs (BCBS, Aetna, UHC)
- Worker’s Compensation (Commercial, US DOL)
Depending on your medical staff’s makeup and your organization’s partnerships, you may need to enroll practitioners into a compilation of several payor programs. The majority of the programs available are local and will likely be accessible through system directories like the Atlantic Information System Director of U.S. Health Plans (AIS). By accessing directories like AIS, your organization will gain an extensive network of health insurance companies operating in the United States.
Step 2: Research Payor Groups
Typically, there is variety in your payor groups’ criteria. You can easily accelerate the process by gathering information about a payor group’s enrollment process. Look on their website for copies of their application to help reduce enrollment delays. You can also learn more about their requirements by asking them:
- Are there special licenses required by the state?
- Is there a preferred submission method?
- Do you permit backdating?
For starters, it is very important to verify licenses when a practitioner is from out-of-state since some states have very strict rules. Crossing over claims from an out-of-state practitioner is dependent on the participating state’s rules. In some situations, certain states will only allow out-of-state practitioners to enroll in Medicare programs.
Another issue is when states have additional requirements for out-of-state practitioners, such as a bond or specific agreements that they must sign. If there is a conflict, the practitioner who is treating an out-of-state patient runs the risk of not receiving payment from the patient’s primary insurance provider.
Step 3: Collect and Submit Applications
While the collection and submission of applications is similar to the credentialing process, the good news is that it is a much shorter process. The main distinction is that much of the leg work in verifying all criteria is done during the credentialing process. Much of the information gathered in credentialing is then credited in the payor enrollment, avoiding duplication. The applications for payor enrollment will ask for information about:
- Identification information
- Education and training information
- Certifications and affiliations
- References and work history
Maintain Progress by Leading Communications
Once the applications are sent, the process is handled by the payor group. The key to accelerating this process is to maintain clear communication until a determination is made. Following up on an application’s progress can clarify any questions and speed up the application process.
Also, not all groups send official letters or have delays in their authorization, which can leave your practitioner in limbo. If the application is denied, you can quickly move toward correcting application mistakes by following up with the group.
Clearly, taking a proactive approach to your payor enrollment process will lead to quicker revenue generation. It is true that much of the process overlaps with credentialing. However by understanding the various nuances that can complicate credentialing, you can truly streamline the process – another win-win.
Maintaining an efficient provider enrollment program is critical to protecting and growing your revenue. Payor Enrollment Services by symplr can help you cut through the noise to get your providers enrolled quickly – all in-house. For more information on Payor Enrollment Services by symplr,
Access symplr's Payor Enrollment Demo Video
To learn more, access the following symplr Provider Enrollment Resources for your hospital or healthcare system:
- Payor Enrollment Data Sheet
- Provider Enrollment White Paper
- Payor Enrollment Webcast
- Provider Enrollment Demo Video
Learn more about the how to streamline the payor enrollment process with our webcast series, Checklist for Payor Enrollment Success Overview. This webcast is presented by our guest speakers Donna Goestenkors, CPMSM of Team Med Global Consulting, and Dina Solis of Sonoma Credentialing Services. With more than 55 years of experience combined, Donna and Dina are experts in their field.
symplr is the industry leader in offering simple, easy-to-implement compliance and credentialing software and services for hospitals and healthcare facilities. symplr provides companies with a means of provider credentialing and a way to manage anyone and everyone entering a facility. Along with provider credentialing and vendor credentialing services, symplr offers a broad range of additional software and services such as payor enrollment, general credentialing, professional practice reporting, provider privileging, peer review, event reporting, visitor management, and exclusion screening.