When it comes to enrolling providers in CMS and commercial insurance companies, much is out of your control. In fact, at times you might feel like an opponent rather than a team member in the game of helping health plans to provide adequate and competent care for their member population.
Aside from enduring lengthy application processing times and striving to walk a fine line between application status checks and stalking payers, frustration can also stem from hearing the notorious “Thank you, but no thank you” from payers when applying for network participation on behalf of providers. You might be left wondering why a payer would deny your provider’s enrollment—and if perhaps you did something wrong in your process, warranting a network denial.
You’re not imagining things and you’re not alone if you feel as if you’re working hard to get your provider paneled yet are getting the familiar red stoplight from payers. However, there are steps you can take after receiving a denial from a payer.
The most critical payer enrollment step for overcoming network rejection
Your sphere of control—or lack thereof—is one thing, but your sphere of influence is quite another. There are ways to exert influence and gain some ground in the daily give and take between healthcare organizations and payers.
Because all subsequent payments flow from enrollment to one or more payers, hearing “no” from any typically is seen at the organizational level as a loss of potential revenue. If there’s ever a place to exert extra effort, it’s at the application stage.
Why insurance panel denials happen
Payers have the ability to set and adjust the number of providers allowed into their networks and to determine their qualifications. They institute limits while walking a fine line to save costs yet ensure their ability to deliver healthcare benefits promised to enrollees. Thus, a provider’s application to an insurance panel can be denied for various reasons, application-error related or otherwise. Often, the payer will suggest checking back in the future if they are currently not enrolling a particular provider type for one or more demographic populations.
In addition, Medicare may not necessarily deny a provider, but there could be geographic areas subject to competitive bidding limitations on reimbursement of certain services or products—or there may be a moratorium on a certain provider type, or in a specific geographic region. Other common reasons for denials include:
- Failure to meet certain criteria or provider standards set by the payer
- Being out compliance with requirements of a payer’s Conditions of Participation
- Over-saturation of a provider type in a community or service area
- Restrictions on or failure to meet additional requirements for out-of-state enrollments
Don’t take ‘no’ for an answer: Go the extra mile to enroll providers
Less-experienced enrollment specialists may be more inclined to take “no” for a first answer, and there is still a dearth of resources to guide specialists when a payer denies network inclusion.
The idea is to submit additional information to get past the payer’s “no,” with an appeal, to clarify what unique or special patient community your provider services, and to request a conference call or face-to-face meeting with a decision maker so you can verbally and effectively convey your message. Persistence counts, but in certain instances you can get beyond barriers using creativity. For example, search LinkedIn under the payer’s company name to see employee titles. Scroll to see the provider management representatives to uncover any common connections and create an introduction.
And when a payer says no, it may be because they see the provider type and base the decision solely on that. Offering additional information about the provider—even when the payer does not request it—may lead to success in enrollment. When using this tactic, clearly communicate to the payer what patient population the provider serves—especially when any of the following are included:
- Indian Health Services
- Chronic condition
- Any non-English-speaking population
Creative steps to successfully enroll providers
Employ these best practice tips to help open closed network doors:
- Get supportive letters from the provider community (referral partners of the denied provider).
- Be open to negotiating lower, competitive rates in exchange for volume, after getting your provider and stakeholder buy-in.
- Suggest a trial period to serve a select number of patients and offer a free comparison analysis after the period ends (again, discuss with provider/stakeholder beforehand).
- Ask for a second level appeal from a decision maker or manager at the payer (check email signatures to determine rank).
- Appeal by phone rather than email or letter (unless the payer requests a formal written appeal).
- Request a conference call or ask for an in-person meeting.
- Offer an in-service conducted by the provider to better understand their services.
- Send a letter of interest that sells a payer on your provider to beef up the application.
Document and share your provider enrollment wins
Getting one in the win column when the provider was initially denied is a big deal and an opportunity to showcase your tenacity. If you’re a manager consider awarding incentives (e.g., bonuses or other recognition/rewards) for successful appeals and the resolution of payer issues.
Overcoming denials takes time, tenacity, and creativity, but it can be done—and it benefits all parties: the specialist who achieves the “win,” the healthcare organization, the individual provider, and most of all the patient.
Take away these enrollment tips
- TIP: Because all subsequent payments flow from enrollment to one or more payers, getting a denial at panel entry is seen at the organizational level as a loss of potential revenue. Ensure your organization has the appropriate resources to review and potentially correct any denials at the application stage in particular.
- TIP: Payers want to know what benefit they would get for adding a provider to an already at-capacity panel. In other words, what need or solution would the provider fulfill? Know the answer to this and always highlight the value your provider can bring to the payer to incent an agreement. For example, if your provider treats patients in-home rather than in-facility, there can be quantifiable cost savings to point out, which could turn around a closed network.
- TIP: To demonstrate provider value to a payer, try offering the payer a way to help track patient compliance, which can assist in the data collection for program initiatives related to the measurement and improvement of care quality, patient outcomes, and health plan performance (e.g., Healthcare Effectiveness Data & Information Set, or HEDIS, audit reporting).
Efficiency is the name of the game once symplrCVO’s Payer Enrollment Services gets your practitioner information. After that, we’ll stay on the ball until providers are par with all requested payers. Outsourcing your enrollment services has never been easier with an expert team on your side.