Provider credentialing and enrollment with the payers is becoming more demanding and strenuous every single day. With most insurance panels getting a bulk load of work, due to the burst in membership applications. And a lot of them being particular about enrolling providers, the process of enrolling or registering your facility is becoming more challenging. Under the circumstances, Outsourcing not only increases efficiency but also makes financial sense. There are four phases of a Provider Enrollment application from the payer perspective. Let’s talk about it.

1. Credentialing: as defined by the Joint Commission, obtaining, verifying, and assessing the qualifications of a practitioner to provide care or services in or for a healthcare organization. So during this process, which hospitals and health plans use, a provider’s education, work history, licensing, malpractice history, and more are reviewed, assuring your patients that they are receiving quality healthcare. This process is a Verification of credentials (Licensure check, NPDB, Employment/Affiliation check, etc.) 

In the credentialing process, it’s imperative that your documents are accurate and they all match. Problems begin when there are inaccuracies. Such as a change of rendering providers or practice ownership and discrepancies between various records. Another problem area can occur when professional references do not respond promptly. It is a good idea to contact your references before they receive a reference request.

Healthcare providers are considered credentialed when they follow insurance credentialing by becoming affiliated with insurance companies, eventually accepting third-party reimbursements. Credentialing comes first and then contracting. As many patients today are becoming aware of the importance of credentialing, they are refusing to visit practitioners who are not in their insurer’s network. This makes it essential for physicians to get credentialed before starting their practice.

2. Provider Enrollment: Your credentialing has been approved, now on to provider enrollment. This is the application process in the form of paper, online, or CAQH. Specified payers use this information to qualify you for products within their health plan and prepare the individual/group/facility for contracting and obtaining participation within a health insurance network. During this process, a request to join the network is submitted to start the application process. You will then go through the credentialing phase, and once approved, move to the final stage of enrollment, which is contracting.

3. Contracting: You have been accepted into the network, and your contract is currently in the process of being loaded by the Provider Relations department. The provider contract is a vital element for any health care provider who wishes to operate a smoothly run facility with high patient satisfaction and on-time payments. However, there are many different types of healthcare provider contracts. Each is filled with lots of unfamiliar legal jargon and confusing clauses, amendments, and stipulations. 

To get a better idea of what to expect in a provider contract and how to negotiate the most beneficial terms, follow along as we break down everything you need to know. By the end of this article, you’ll also learn the benefits of using a healthcare contract management system for your healthcare facility. 

Contracting is the process of applying for and obtaining participation with insurance plans. Once the credentialing phase is complete, and the payer has approved the provider, the payer will extend a contract for participation. Healthcare facilities and insurance payors often engage in negotiations to set and meet some targets and benchmarks through contracting. The requirements of contracts differ by specialty, practice, size of the healthcare organization, and location.

Contracting or being ‘in network’ is an optional relationship offered by most insurances that makes you an official ‘participant’ with that insurance. Being contracted restricts your freedom to charge and collect from patients and often involves negotiating with that respective insurance company. That said, being in-network means you’ll likely get a steadier patient stream because patients typically receive better coverage for in-network services.

Often providers enroll in a plan and then never review the performance of the contract. Years go by; insurers do not update your contract to reflect updated reimbursement rates. Does your biller or associated billing company periodically review contract performance and update your contracts?

4. Participating: You are participating and may see patients for the specified payer.

You are done now with your Provider Enrollment Application. Congratulations!

Contracting Providers have been helping providers with their Provider Enrollment Applications and credentialing for years with our vast experience of more than 40 years. Because we go through paperwork and know how to avoid setbacks. We specialize in the language payor groups and insurance use, helping us glide through data and rarely make mistakes. That’s why having dedicated personnel to watch the changing industry is a must. And we pay close attention to requirement updates per state and notify you if something has changed. This is a full-time task that doesn’t allow room for error.

Between using internal resources, time, and labor, expenses associated with keeping some services in-house add up. helping ongoing expenditures stay low and reduce tasks that clutter you or your staff’s to-do list. Also, we are constantly communicating with payor group representatives, and have developed exclusive access to many of them. We ignore automated systems and middlemen because we have the direct line to who we need. Contracting Providers operate in a limited capacity – focusing on specific healthcare industry tasks – making us fast and efficient at what we do.

You may book a Free No-Obligation Consultation with one of our experts here.