Payor Enrollment FAQs Answered
Bringing new providers on board is an exciting, yet complex process with plenty of moving parts. If you’ve ever hired a physician or mid-level provider, you understand how much work the process entails. Payor enrollment is one of the most critical, yet misunderstood pieces of the puzzle. While getting your providers billable sits right on top of the to-do list, completing the process the right way requires more expertise, diligence, and experience than most people assume.
One of the most significant issues around payor enrollment is that many underestimate how tedious, lengthy, and time-consuming this process can be. Keeping up with the ever-changing regulations and rules of each health plan can easily become a seemingly impossible task, leaving you and your staff feeling stressed and frustrated. Not knowing the rules does not alleviate the potential negative consequences. Failure to adhere to the required timelines can result in delays in enrolling providers with health plans, which in turn may stall the entire process.
To help you get a better understanding of the payor enrollment process and show you how to navigate it effectively, we’ve put together a list of frequently asked questions with some of our best practices.
Payor Enrollment FAQs
1. What is payor enrollment, and how does it differ from credentialing?
Many people are confused about the difference between provider credentialing and payor or provider enrollment. Provider credentialing is primary source verification, which is essentially a type of background check put in place to verify the credentials, degrees, and employment history of medical providers.
Payor enrollment - commonly referred to as provider enrollment - is the process of enrolling providers with health plans. Why is it essential to enroll with payors? By enrolling, providers are then considered “in-network” or “participating.” Becoming listed as such is crucial, as most patients will not pay the higher copay to be seen out-of-network.
The reluctance to pay more to see non-participating providers stems from the fact that the high costs of health insurance already burden most people. Since 2015, healthcare costs have skyrocketed. Patients today pay an average of 30% more for health coverage in the form of deductibles and out-of-pocket expenses (1).
2. Which payors do I need to get my providers enrolled with?
Your providers should enroll with all major payors in your region. Figuring out which health plans are the most common in your area is the first step in the process. To help you decide which health insurers you may want to do business with, take a look at the different groups of payors.
National vs. Regional Health Plan Providers
The six largest organizations are Aetna, CIGNA, WellPoint, Humana, United HealthCare, and BlueCross BlueShield. The five biggest companies provide coverage for about 50% of the insured population, encompassing over 100 million people (2). So as a rule of thumb, you want to make sure that your providers are enrolled with the top insurance companies.
While big health plan providers have been consistently outperforming regional payors (3), smaller insurers can play a significant role in their respective geographic areas. With their ability to focus on the needs of their local markets, their membership base can be quite substantial. Find out which local plans are the most prevalent in your area by inquiring at the hospital business office. You can also ask other physicians in town to make sure your physicians are enrolled with all the key players in your region.
Government & Commercial Insurance Providers
Government-operated programs and private health plans differ from one another in various ways, but it doesn’t mean that one is necessarily more important than the other. Enrollment processes with government insurance providers, such as Medicare and Medicaid, tend to be a bit more complicated. Keep that in mind and allocate enough time to complete the process within the required timeframe.
To ensure that you don’t miss any major plans, become familiar with the national and regional payor landscape. Understand that the enrollment process is likely to differ from payor to payor and state to state. Do your best to follow the insurer’s unique set of rules and requirements.
3. What is the biggest source of confusion around payor enrollment?
Underestimating the length of time it takes to complete payor enrollment with each health plan is by far the most significant issue that gets practices regularly in trouble. Most have no idea how time-consuming these processes can be or the amount of information that's required. Here are two situations that can happen if you don’t start the process early enough:
- Your new provider begins seeing patients before getting enrolled with payors. In this scenario, the provider may not be able to get reimbursed for services rendered, which will lead to a loss of revenue.
- You find yourself having to turn away patients. This option also has a price tag. If you decide to turn patients away, you are not likely to see them come back, as they will seek out another in-network provider in your area.
4. How long does the payor enrollment process take?
The length of the process can differ greatly from one health plan to another and one state to another. In general, 30-90 days is a reasonable estimate; however, 4-6+ months isn’t completely unusual. Most insurance companies will not allow you to submit your application sooner than 60 days ahead of the provider’s start date.
5. What advice can you give me to help streamline the process?
Here are a couple of tips to help you make payor/provider enrollment as seamless as possible.
- Choose someone who is experienced in payor enrollment. Many people assume that enrollment means nothing more than filling out a few forms, but this couldn’t be further from the truth. You need to decide who you entrust with completing the process successfully. Putting the wrong person in charge can lead to costly mistakes and unnecessary delays.
- Make sure you have all your documents together. Even before beginning the enrollment, have a discussion with your new providers and request all documents that are necessary for completion. Ask them to locate any and all paperwork that pertains to their medical license or practice. Internship, Residency, Fellowship Certificates, Medical Degrees, Hospital Privileges Letter are some examples of the documents that are required.
- Set realistic expectations. Let the providers know what payor enrollment entails and why it is crucial. Make sure they understand that their cooperation is necessary to avoid any delays. Ask them to be responsive and communicate timely with the person in charge of payor enrollment. Alternately, ask them’’ to appoint someone else who is willing to respond to last-minute requests for more information quickly and efficiently.
6. Why should I consider outsourcing payor enrollment?
There are several compelling reasons why an increasing number of healthcare organizations decide to hire outside firms to manage payor enrollment for their practices. Seeking out experts who specialize in this area offers several benefits.
Companies, such as symplr, not only have an in-depth understanding of payor enrollment and credentialing, but also the expertise, contacts, and familiarity to make the process as smooth as possible. Due to their many years of experience, they also know how to escalate issues and appeal unfavorable decisions.
Reduce enrollment data errors
Working with an enrollment specialist will drastically reduce the potential for enrollment data errors, one of the most common causes of delays. This benefit alone will save you tremendous headache and frustration. Making fewer errors will improve the overall experience and help you receive insurance payments faster.
Save money on training your staff
When you outsource your payor enrollment, you don’t need to worry about training your staff and putting all the responsibility on one person. Your payor enrollment specialist will gladly take all the bothersome tasks off your shoulders. He or she will do the follow-ups, make the phone calls, and send the necessary faxes and emails.
7. Do you have a resource to help guide me through the process?
Yes, we do. Click to download our white paper about the Top 10 Payor Enrollment Mistakes and get expert advice on how to avoid making them.
About Susan Ward
At symplr, Susan Ward is the Director of the Payor Enrollment Service product line. With 20+ years’ experience in physician practice management and provider enrollment, Susan is responsible for enrollment operations and relationships with Healthcare Systems, Hospitals, Physician and provider groups focusing on increasing the efficiency of provider onboarding during acquisitions, employment or new practice start up. Her previous experience includes over nine years at Community Health Systems in Franklin, TN, where she served as the Manager of Provider Enrollment, Acquisitions and RHC Enrollment. Her strengths in organizational structure, problem solving and relationship building, as well as her background and knowledge of CMS guidelines, are an asset to Payor Enrollment Services.