Healthcare Credentialing | symplr Blog

Provider Enrollment: Start Early

Written by Kimberly Avello | Apr 17, 2017 9:05:03 PM

Have you recently hired a healthcare provider to join your practice? Making sure the provider becomes enrolled with commercial and government insurance payors is essential to maintaining a steady patient base and cash flow to your practice. To ensure the enrollment process moves along efficiently and in a timely manner, you will need to submit the provider’s application and required documents as soon as possible to the top payors in your area.

Be aware that the process for most commercial credentialing and contracting will take an average of 90 to 120 days to complete. Some plans can take even longer, making it even more important to begin right away. Many new practices, or practices hiring a new provider, make the mistake of beginning the process a month prior to a provider’s start date. This creates frustration when the practice finds it cannot receive in-network reimbursement for another three to four months until the contract process is complete.

For a provider to be able to be reimbursed, a two-part process must be completed with each commercial insurance company.

First is the credentialing process, during which the payor verifies the provider’s education, training, and malpractice history. Certain payors can pull this information from the CAQH database. Most payors have a credentialing committee that will need to review and approve the provider’s file to move forward. The committee will approve or reject the application according to the company’s own credentialing requirements, a process that usually takes between 60 and 90 days.

Second is the contracting process, during which the provider is given the network contract to review, sign and return for execution. If your practice currently holds a group contract with the payor, the provider may not have to sign an additional agreement, as the practice will be able to link him or her to the group contract. Only after the network contract is effective can your practice bill for services rendered and receive in-network reimbursement. It is important to know that most commercial plans do not give a retroactive effective date.

Enrollment with Medicare can begin 60 days prior to a provider’s start date. The application can be completed directly on Medicare’s PECOS website or manually with an 855 paper application signed by the appropriate individuals and mailed in. Depending on Medicare’s workload, it may take up to 180 days to complete the enrollment process. This timeframe can be shortened if the application is submitted online via PECOS, but a shorter time is not guaranteed.

Submitting your applications correctly the first time will minimize the time delays for your new provider. If you are not fully prepared to include all necessary information to complete the process on the first submission, an incomplete or inaccurate application will cause delays in obtaining an effective date. When you pay attention to detail, stay current on attestations and make sure your CAQH file is up to date, delays can be avoided.

To save time and speed the reimbursement process, you may want to outsource your payor enrollment to a third party. symplr’s dedicated payor enrollment team is a group of highly skilled individuals who work exclusively with payors and providers. With their efficient processes and established workflows in place, your payor enrollment process can be shortened to weeks instead of months and your providers can become billable faster.

To learn more about the payor enrollment process and how outsourcing enrollment services can benefit your organization, download the white paper, Navigating the Payor Enrollment Process.

We offer complete client support to help you navigate the complexity of provider enrollment, saving you time and money. Learn more about Payor Enrollment Services at www.symplr.com/products/payor-enrollment-services or schedule a demo at sales@symplr.com.