What to Do If Your Enrollment Application Is Denied

Getting physicians enrolled with a healthcare network is no longer a straightforward process with a couple hurdles to clear. Instead, it’s an obstacle course you may have to traverse frontwards and backwards. For credentialing experts, this process begins when all relevant provider information is collected and verified and the enrollment application is submitted. Then, the follow-up phase begins until the network renders a decision.

But not so quick! Your work doesn’t end there – especially if your application is denied. This is becoming a more common occurrence due to payors narrowing their networks as a cost-containment strategy. Now, payor enrollment specialists must doggedly pursue health insurance networks until a provider is accepted into the plan. But what happens if your application is turned down? For starters, don’t take “no” for an answer, particularly the first time. Networks often re-evaluate their needs and your provider could be re-considered down the road.

If the worse happens – you are denied network enrollment – here are four steps to take:

1. Find out why your application was denied and when you can re-apply

Don’t forget your application could simply be denied because of timing – the network may already be at capacity or not need your provider’s specialty at this time. Don’t fret. As mentioned earlier, payors often re-evaluate their network needs. They may have a void that your provider can fill in the future. The best tact is to determine why your provider was denied and to re-submit the enrollment application.

2. Appeal and re-appeal with supportive letters

This may seem obvious, but it’s a good idea to ask colleagues, referring physicians, and case managers to write letters of support. When pleading your case to re-appeal, be sure to find the key decision-maker or person primarily responsible for managing the network enrollment contract. You can do this by contacting the payor or searching for contacts on LinkedIn. When you find the appropriate person, reach out to them directly.

3. Ask for a single-case agreement or a trial basis option

What about single-case agreements or trials based on the patient, area, or period of time? Payors will often offer your provider this option. Don’t forget to keep track of how many single-case agreements you are racking up over a period of time. It is worth pointing out to the payor if your organization is consistently seeing patients through single-case agreements without the benefit of network enrollment. Then, you can build a strong case for enrollment – simplifying the process for both parties. You can also use quality/patient satisfaction surveys of those single instances to convince them of the value your providers would bring to the network.

4. If appropriate, offer discounted rates

What about offering reduced fees to get your foot in the door with a specific network? First, ask your provider if they are amenable. If your provider can come in slightly under the competition, the payor may be willing to accept them into their health plan.

No doubt, the narrowing of today’s health insurance networks means you must be persistent and maintain constant communication. Don’t be afraid to speak up and send friendly reminders to the payor until your provider is approved. Sometimes, it’s really just a matter of gently bugging the payor until they accept your request.

Ready to streamline your payor enrollment process with symplr? When you partner with symplr for payor enrollment, you gain access to an entire team of enrollment experts. Clients can expect to cut their enrollment processing times by weeks and even months over their in-house systems. To learn more about Payor Enrollment Services by symplr, Schedule a Demo with us now!

Learn more about streamlining the payor enrollment process with our webcast, “Achieving Payor Enrollment Success.” This webcast is part of series presented by guest speakers Donna Goestenkors, CPMSM of Team Med Global Consulting, and Dina Solis of Sonoma Credentialing Services. With more than 55 years of combined experience, Donna and Dina are experts in their field.

Payor Enrollment from symplr


Donna Goestenkors

About the Author
Donna Goestenkors

Donna is a full time healthcare consultant, speaker, author, educator, and mentor serving the Medical Staff Services industry for over 40 years. Her diverse project experience includes assignments in every work environment and rapport building among all levels of professional and executive staff. Donna is a past President of NAMSS and her client work covers all of the industry's environments from Healthcare Systems to critical access hospitals.

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