Payor enrollment, or provider enrollment, is the process of applying to health insurance plans or networks for inclusion into provider panels. This can be a tricky (and lengthy!) process that puts strain on multiple departments in your facility. If you’re feeling uncertain about where to start – start here! Read on to learn how you can get going on your own, the best resources, and what options you have for help.
First, there are federal and state insurances (Medicare and Medicaid, respectively). Then there are the commercial and private insurances like Aetna, United Healthcare, Humana, Cigna, etc. Finally there are smaller, local area or regional-type health plans included (still in the private and commercial area). Keep in mind that some states have exceptions, for example: in California, Medicaid is called Medi-Cal - and in some states you have Medicaid and numerous managed Medicaid programs.
Special Mention: Although the names of these types of enrollments differ, the parallel is that in medical staff services we currently have various regulations and accrediting bodies that need to be followed as well.
Identify your organization’s internal provider enrollment processes before starting and follow any required processes. If you’re enrolling a group, the individual also needs to be enrolled so those benefits can be re-assigned to the group. Then identify the desired health plans to enroll in (depending on your organization, those could also be predetermined for you).
Once you’ve identified whom and with which plan, you’re ready to contact the provider enrollment or provider relations area departments (you can refer to each payor’s website for help). Sometimes payors have their processes directly on their website and sometime you have to do a little digging. Call them!
There are a few key points you'll need to find out:
Yes! You have a few options if you don’t want to do everything by yourself.
Some resources we have available (that can help manage processes, provider data, application, expirables, reports, etc) are with credentialing software. Software can help automate the application process by auto-populating, tracking, and even submitting the applications and is efficient in managing the overall process. This is a huge timesaver. Some software products will allow you to enter email addresses or fax numbers so you can actually click a button to submit, which can be extremely helpful in streamlining the process. Every payor’s submission method can be different.
Try using software you may already have to take care of a few of your enrollment headaches. For paper applications download the full version of Adobe Acrobat Pro.
No – you still have work to do! During this period, be sure you keep in good communication with the payor and the provider and be prompt in your follow-ups. Basically… stay on their good side! And if you know that you’re going to have a gap in communication while you pull together some trickier documents, just follow up to let them know that you got their email and are working on it (and try to always give a timeframe).
Over 39 years in the Medical Staff Services industry, I have seen my fair share of problems. Here are the three biggest I see over and over again—
Processing timeframes are tricky to define because they vary by payor. What I usually do is I contact the plan and ask for an estimate – I’ve seen them be as short as 1 month (very rarely) all the way up to 180 days. Just go into it with that mindset and always advise the providers ahead of time. Another plug for using a full service like with symplr is that they have the resources to get it done 50% faster than you can do it on your own.
The comprehensive directory of health plans for 2015 called the Atlantic, available through Atlantic Information Services, will give you all the United States health plans and it includes member enrollment, plan type, demographics, and contact information.
You can also go online and connect with people in your industry – so many folks out there have been through the same thing and can give you guidance. Ask questions or even find someone who can mentor you.