According to the Medical Group Management Association (MGMA), medical coders are the most challenging revenue cycle positions to fill, with billers coming up close behind. Given the importance of these roles within a financially successful practice, having efficient processes in place is more important than ever.
Provider enrollment and credentialing are essential processes to get right. They’re the key to getting paid by private and federal payers and necessary to ensure quality healthcare experiences—but nonetheless the manual effort to keep paperwork in line can be time-consuming and expensive.
Let’s dig into provider credentialing and provider enrollment, and some best practices to keep your team flexible and productive!
Medical Credentialing: A Foundation for Quality Care
In the healthcare field, credentialing refers to the process of verifying a healthcare provider’s qualifications, education, training, experience, and professional background. This requirement ensures that only qualified and competent providers are authorized to deliver care, creating safeguards against malpractice claims or disciplinary action.
The credentialing process protects patients by verifying that providers meet the required standards to deliver quality care. In this way, credentialing helps maintain trust in the healthcare system.
How Does Credentialing Differ from Provider Enrollment?
While credentialing and provider enrollment are closely related, they are distinct processes. Credentialing focuses on verifying your qualifications and background, while provider enrollment involves applying to payers to become an approved provider.
Documents and Information Required for Credentialing
The credentialing process requires extensive documentation, which may include:
Proof of education (diplomas, transcripts)
Licenses and certifications
National Provider Identifier (NPI)
Malpractice insurance coverage
Professional references
A detailed work history
Background checks for disciplinary actions or legal issues
A smooth credentialing process depends on accurate and complete information. Errors or missing documents can delay approval and, as a result, the provider’s ability to start treating patients.
Essentially, we can think of credentialing as the foundation for legal practice—it establishes your credibility as a provider. Enrollment builds on that foundation, allowing you to bill and receive reimbursement from payers.
Provider Enrollment: First Step to Earning Reimbursements
Provider enrollment (or payer enrollment) is the process of becoming authorized to bill commercial insurance companies, government programs like Medicare, and other payers.
Why Is Provider Enrollment Important?
Provider enrollment allows providers to join the insurance plans accepted by their healthcare organization or practice. It’s also a legal requirement. Most insurance companies and government payers, like Medicare, require providers to be enrolled before they can submit claims. Being in-network can bring in new patients and secure better reimbursement rates. On the other hand, failure to enroll can mean providers can’t submit claims to certain payers.
Typical Steps in Provider Enrollment
The provider enrollment process generally follows these steps:
- Gathering Documentation. This involves collecting and organizing essential credentials, licenses, supporting documents, and signatures required for provider enrollment.
- Application Submission. Providers must submit an application to the insurance company or government payer, providing detailed information about their practice, credentials, and qualifications.
- Review. The payer verifies the information provided in the application, ensuring the provider meets their requirements for participation.
- Approval or Denial. Once the application is approved, the provider is officially enrolled, and you can begin billing for services.
- Updates and Maintenance. After initial enrollment, providers must maintain their status by updating their information regularly and complying with all payer requirements.
How Do You Prepare for Provider Enrollment?
Preparation is key! Before diving into applications, gather all required documentation, including credentials, licenses, and proof of malpractice insurance. Ensure all information is up-to-date and accurate. To avoid delays, make sure to account for the specific requirements of any payers with whom you plan to enroll.
How Long Does Enrollment Typically Take?
The timeline for provider enrollment can vary widely depending on several factors, including the payer’s requirements, the completeness of the application, and the efficiency of the credentialing process. For new providers, the enrollment process typically takes between 30 and 90 days.
However, if there are any complications with an application or the payer is handling a high volume of requests, the process can stretch even longer—sometimes up to six months. The best strategy is to begin early and stay proactive, regularly checking in on the status of your applications to avoid unnecessary delays.
Considerations for Different Healthcare Settings
The provider enrollment process can vary depending on the healthcare setting in which you practice.
Hospitals vs. Private Practices
Enrollment requirements can differ significantly between hospitals and private practices. Hospitals often have more complex enrollment processes due to their size and the variety of services they offer. Additionally, hospitals may have dedicated staff or departments to manage their enrollment and credentialing.
In contrast, private practices often lack the same resources, making things challenging for solo practitioners or small therapy clinics. As these practices expand, so do their operational complexities. They have to manage more providers, juggle additional deadlines, deal with more payers, and sometimes oversee locations in multiple states.
Enrollment Requirements by State
The enrollment process is subject to state-specific regulations, which can vary. Certain states may require additional credentials or documentation, and enrollment procedures may differ depending on the type of provider.
If you practice in multiple states or plan to expand your practice, you must account for and comply with the specific requirements for each state. Always consult your state’s licensing board for the most accurate, up-to-date information.
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Maintenance and Re-credentialing: Ongoing Responsibilities
Once providers are enrolled, the work isn’t done. Maintaining enrollment status requires ongoing effort and attention.
How Often Do Providers Need to Update Their Information?
Providers must renew or update their information periodically. This process, known as recredentialing, re-attestation, or revalidation, typically occurs every two to three years, but requirements vary between organizations. For example, Medicare revalidation occurs every three or five years.
Consequences of Non-Compliance with Enrollment Requirements
Failing to comply with enrollment requirements can have serious consequences. If your therapists’ enrollment status lapses, you may be unable to bill for services rendered during the period of non-compliance. This can lead to significant financial losses, damaged relationships with payers, and disruption of patient care.
To stay compliant, it’s crucial to:
Regularly Update or Re-attest to Your Information. Ensure each payer has current credentials, licenses, and other relevant information. This includes updating your practice address, contact information, and any changes in professional status.
Track Deadlines. Use a credentialing software solution that alerts you to upcoming renewal dates and deadlines.
Stay Informed About Policy Changes. Payer requirements can change, so stay informed about these changes to ensure ongoing compliance.
Common Challenges in Provider Enrollment and Credentialing
Managing provider enrollment and credentialing can be complex, especially when data and workflows are siloed. Handling credentialing processes on paper or using separate spreadsheets disconnected from your EMR and billing software can lead to disorganization and errors. Here are some common challenges practices face:
Data and Workflow Siloes. Managing credentialing separately from your EMR and billing software can result in inconsistent data, duplicate efforts, and missed updates.
Missed Deadlines. Failing to track application deadlines and renewal dates can lead to claim denials and patient care delays.
Documentation Management. Keeping documentation consistent across various systems and touchpoints is crucial, but this can be difficult without a centralized system.
Lack of Scalability. As your practice grows, managing increased responsibilities with limited resources becomes challenging, leading to potential bottlenecks in your credentialing process.
Do You Need Credentialing Software?
Managing the credentialing and enrollment processes manually can be time-consuming and error-prone due to paperwork and potential delays caused by incomplete applications, lengthy verification processes, and changing payer requirements. Credentialing software streamlines enrollment by offering a more efficient way to manage credentials.
Here’s what credentialing software can do:
Centralize Documentation. Store all provider information in one secure location.
Automate Tasks. Simplify application completion and submission.
Track Application Status. Monitor progress with each payer in real-time.
Reduce Errors. Ensure application accuracy with built-in data validation tools.
Smooth Onboarding. Significantly expedite the onboarding of new providers.
How Can Automation Improve the Enrollment Process?
Automation can significantly reduce the time required to manage credentialing and enrollment. By automating the time-consuming steps of deadline management, application submission, document tracking, and checking for status updates, credentialing software helps you avoid errors and delays.
What Software Solutions Are Available for Enrollment Management?
There are many software solutions designed to help manage provider credentialing, including application submission and status monitoring. Provider data management (PDM) software manages provider data and can help organizations and practices store and organize credentialing documentation.
Note, however, that these solutions typically require integration with third-party vendors, which can create inefficiency and added cost.
If you just have a downstream system that's not connected, you might make an update in your credentialing system or in your provider data management system and it’s not going to update that billing system or EHR—your data is going to be out of sync.
Credentialing Software for Rehabilitation Therapy
For a rehab practice, enrollment and credentialing are more than just administrative tasks—they’re essential for keeping your doors open. They ensure your therapists can participate in insurance plans, get reimbursed for their services, and provide care to patients who need it. This helps maintain a healthy cash flow and ensures your practice can continue to operate smoothly.
Raintree’s built-in credentialing solution offers a unique advantage for rehab therapy practices. By providing a centralized solution within the EMR platform, Raintree’s credentialing management solution can help your practice automate and centralize:
- Primary Source Verification
- Expirables Tracking & Document Storage
- Alerts & Task Management
- Automatic Schedule Blocking