I have been in the payor enrollment industry for 27 years, so people often ask me how the industry has changed. Steadily, I say, with a few punctuations of accelerated change.

Payor enrollment has always been about two things: developing deep knowledge of health plan requirements, and serving providers throughout the complicated enrollment processes. In my database right now, I have well over 1000 payors’ applications, each requiring hundreds of details about the provider. It’s not too hard to imagine what it takes to be successful in this position. It takes organization, time management, excellent communication skills and conscientiousness are vital.

How Technology Has Advanced the Provider Enrollment Process

Technology changes have had a big impact on how we organize and manage provider applications. Surprisingly, this happened quite recently. Before 2005, my department wrote out every application by hand.

For years, we kept enrollment documents and application copies in giant three-ring binders and had walls and walls of old enrollment records. Some applications were about 40 pages long, and every single one was filled out by hand. There were many nights I went home with writer’s cramp!

Imagine how relieved I felt when we got Adobe fillable forms and I could type in the application.  A couple of years later, we began to use the Vistar platform for populating electronic applications, tracking and reporting. That was 2007, and at first, we struggled as a department to trust the electronic process. Part of the struggle was that applications, while filled and managed digitally, still needed a wet signature. We had to print and mail them to the providers to secure signatures, the provider would mail them back, we made copies for our files and then submitted them to the insurance carrier.  For a couple of days each month, it was like I ran a post office!

As a manager, I often encouraged the department to scan the signed application and shred the paper, but still, we had staff who didn’t feel comfortable without paper copies as a backup. It’s amazing to look back at how gradual the change to digital applications occurred. You might think the arrival of enrollment software like Vistar would encourage us to adopt and trust the digital process completely. It did not. It’s always hard getting out of your comfort zone, especially when what you are already doing seems to be working.

It was not until we began moving offices that we decided not to move that paper with us. It was time for a new process and digital applications had become the norm. Today, there are still a few plans that require a wet signature, but for the most part, it’s all done on email and on online portals. Once we left paper behind, we could look back with hindsight and appreciate the difference digital applications made in our work.

Portals, CAQH, and Standardization (please!)

Our writer’s cramp subsided, but the payor enrollment industry remains full of pain points.

One common pain point is the pressure to adapt quickly to the growing diversity of provider types. It used to be that we enrolled mostly doctors, nurse practitioners and PAs. Today, we enroll physical and occupational therapists, allied health professionals, social workers, drug and alcohol rehabilitation clinics, and the list goes on. Because our industry has changed gradually, we have been able to absorb the complexity of the enrollment side effectively and maintain our knowledge of the processes. As the healthcare industry continues to change, with telemedicine, for example, we expect more adaptation in the years ahead. 

One of the biggest pain points in the industry remains the lack of standardization across payor enrollment processes and between states and payors.

I want to give payor portals and CAQH credit. CAQH rose to prominence as the standard application that many (but not all) payors elected to adopt, and software applications such as Vistar and Cactus have helped us become more productive. These innovations have been responsible for significantly streamlining our enrollment processes. They turned the Wild West into a tamable business process.

Still, there are hundreds of payor applications each with individual rules and nuances, and the rules are constantly changing. Some payors are still using paper applications.

In my 27 years of experience, the only way to get ahead of this complexity is to commit to developing a deep knowledge about each state’s and payor’s specific rules and expectations and to keep current on all new regulations. It is so important to have first-hand knowledge of the provider enrollment process that I prefer to hire only experienced enrollment specialists. All of my staff have developed their skills through on-the-job training and come to us with a vast knowledge of the enrollment process. There is no school for this.

All of these pain points make our industry attractive to new entrants, and we at symplr are excited about a future when we can partner closely with our industry peers up and down the value chain. One thing we’ve learned over the years is that there is no algorithm to replace what we do. Yes, we use our own symplr software, Vistar and Cactus, to speed up the enrollment process, but we still need seasoned staff to manage the process. Only deep process knowledge can get you ahead in this business, and that hasn’t changed.

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