The What, Why, and How of Provider Enrollment

When can you provide the best healthcare services to your patients? When your healthcare facility generates revenue! And to generate revenue, you must have a list of patients who view your services and facilities as “in-network.” An in-network provider contracts with a health insurance plan to provide healthcare services to its members.

Continue reading the blog to find out what provider enrollment is, why it is important, and how it works.

What is Provider Enrollment?

Provider enrollment or payor enrollment is the process through which healthcare providers or facilities apply for inclusion in a health insurance network. People who carry that particular health insurance plan become more likely to seek treatment from you if you are ‘in-network’ with the provider.

Why is Provider Enrollment Beneficial for Your Practice?

Despite being a complex and time-consuming process, payor enrollment offers several benefits, making it a priority for all healthcare providers and facilities. Successful provider enrollment can help your practice attract new customers, generate more revenue, and expand your healthcare programs.

At the same time, failing to carry out the provider enrollment process may result in enormous financial losses, limit your ability to offer the best healthcare services, and damage your reputation. Therefore, payor enrollment not only adds value to your practice but also prevents debacles.

How Does Provider Enrollment Work?

The provider enrollment process consists of three stages: Application, Credentialing, and Contracting.

Stage 1: Application

The provider enrollment process begins with identifying the insurance companies you want to partner with. While making this decision, you must become familiar with the insurance plans that people commonly buy. Remember to choose the most popular network and not just the largest. This can help you gain the most benefits for your practice.

Step 2: Credentialing

When the health insurance company receives your application, they verify your license, competence, and qualifications as a healthcare provider. This process, known as provider credentialing, helps insurance companies ensure that you meet their credentialing requirements. After verifying your credentials, the credentialing file goes to the Credentialing Committee for approval. Once the Credentialing Committee approves the file, it moves to the next stage. Insurance networks can take up to 90 days to complete the process.

Step 3: Contracting

After verifying your credentials and approving your practice, insurance companies will offer you a contract for participating. The contract includes the terms and clauses dictating your partnership with the insurance company. This contract officially makes you or your healthcare facility an in-network provider.

Once you receive the contract, you must review the language, reimbursement rates, and other details about your participation. Additionally, you can negotiate better reimbursement rates at this stage before signing the agreement. After signing the agreement, you will get a provider number to bill the insurance plan and receive reimbursements for your claims. Insurance networks can take 30–45 days for this complete process after credentialing.

What is CAQH and How Does It Help?

The Council for Affordable Quality Healthcare (CAQH), a nonprofit organization, offers a quick fix for one lengthy aspect of the payor enrollment process. Earlier, every insurance company had its unique provider enrollment process, i.e., the requirements for application forms and credentialing varied from one company to another. As a result, providers were forced to modify their applications for each specific payor, causing a waste of crucial time.

To tackle this problem, CAQH developed a universal application that helps providers upload their personal information and supporting documents. Insurance companies can access this online application to verify a provider’s credentials and add them to their insurance network.

How Can a Provider Enrollment Specialist Help With the Process?

Since every insurance company has unique requirements to enroll a provider, the payor enrollment process involves filling and submitting dozens of forms. Moreover, you will need to start the application process all over again if there is even a minor mistake in one of the forms. This can make provider enrollment a time-consuming and frustrating process. A provider enrollment specialist can help in the following ways:

• Taking notes of the different health plan applications on your behalf
• Setting up a priority list to determine which application needs your attention at the moment
• Submitting all due paperwork before the deadline

A provider enrollment specialist takes care of all the tasks required to complete provider enrollment in the payor networks.

STAT MedCare: Making Your Provider Enrollment Process Easier

While there has been some standardization of the payor enrollment process through CAQH, it still requires manual intervention and regular follow-ups to ensure accuracy and timely completion. This is where outsourcing your enrollment needs to a provider enrollment specialist can help.

STAT MedCare, one of the largest provider enrollment companies, has successfully submitted over 1,000,000 enrollment applications. By understanding your requirements, our professionals will offer you customized solutions for the payor enrollment process. So what are you waiting for? Get in touch with an expert at STAT MedCare to learn more about our services!