Leadership | 05.26.20
The Payer Enrollment Process
by Lisa Goodwin, BS, CPCS, CPMSM
Payer enrollment: two words that can strike fear into any CFO. The process by which every physician, advanced practice nurse, physician assistant, pharmacist, counselor, dietician, social worker, physical therapist, and any other caregiver that can bill for services is enrolled with the insurance companies. This process is required to be completed prior to a provider being able to join an insurance plan provider panel and get paid for services rendered to those patients. Once this process is complete, providers are considered to be in network, and in most cases patients pay less of a copay when seeing in-network providers.
This introduction to payer enrollment is just the 50,000-foot view — there is so much more to it. I have found that there are many challenges surrounding the work of payer enrollment. The biggest challenge is finding knowledgeable, qualified people to do the work. Payer enrollment is highly specialized and, like medical staff credentialing, people tend to stay in positions, which makes recruitment difficult. Other challenges include the changing requirements from the payers. Every facility and healthcare system is contracted with different payers that have different applications, different processes, and the payers themselves are changing. The beginning of 2019 saw the finalization of CVS’s acquisition of Aetna, the CenteneWellcare $17.3 billion merger, and there will be more to come in 2020. The healthcare industry has been consistently growing for the last 20 years and is predicted to maintain the highest growth in employment.
The payer enrollment process begins with the completion of a provider application. More than 24 health plans, from Aetna to UnitedHealthcare, use the Council for Affordable Quality Healthcare (CAQH) application.
This knowledge is helpful, because once the CAQH application is completed online, the only additional information required by these payers is a provider data form. If a commercial payer does not use the CAQH form, they most likely have their own application for completion. In order to enroll a provider with Medicare, the application process is a little more detailed. Although Medicare still accepts a paper application, the process is quicker through PECOS, their electronic system. Getting access to PECOS requires the organization to create an account through Identity & Access Management System (I&A). With that access, providers can grant surrogacy for the facility to complete Medicare enrollment.
There is an overlap in information collected between payer enrollment and medical staff credentialing. Each requires a statement attesting to any professional sanctions, criminal history, affirmation of abilities, litigation, and malpractice coverage history. Each also asks for professional references, work history, licensure, and board certification or, if board eligible, a date when the physician expects to complete their board exams, just to name a few. Sometimes providers have sensitive information to disclose as part of the application process. In order to maintain the highest confidentiality and not have this information stored in multiple locations across the organization, my facility decided to move payer enrollment into the medical staff services department.
At my organization, we have found that creating relationships with key stakeholders is valuable. In addition to our credentialing partnership, we meet regularly with recruitment and contracting. Having a strategic partnership with recruitment means we have early access to new providers who have signed contracts and are ready to begin the enrollment process. At our meetings, we review the status of providers on our current worklist to determine if a provider can start on time or if their start date needs to be adjusted. Quarterly meetings with contracting allow us to discuss new payer contracts and requirements, as well as any issues we may be having with payers.
Many of us in the medical staff field have perfected the credentialing process so that we can get a provider on our medical staff in 30–45 days, sometimes even sooner. But, when it comes to enrolling providers with CMS and commercial payers, the process takes considerably longer and much of it is out of our control. As with any detail-oriented process there are challenges, and some challenges begin right away with the provider response time. In many situations, it is not just a single provider moving to the area and starting a new job, it is a family moving. This means that once the contract has been signed, the provider is focused on getting their life in order and moving to a new location, not on checking their email or knowing where their board and medical school certificates are. Then, there is licensure, physician, and advanced practice professional applications that cannot be submitted to the payers without both a state license and a DEA. The process of onboarding a new provider can be thought of as a house of cards — if the foundation is not solid, the entire house will collapse.
Our facility has developed a checklist that we include in our new provider packets, and applying for state licensure is at the top of the list. We let providers know that seeing patients is contingent on how quickly they can obtain licensure. After all of your hard work, sweat, and tears, the applications are submitted, your work is done, and now you are just going to wait for the enrollment letters to quickly begin coming in, right? Well, not exactly. This is when the out-of-your-control part starts. Unless you are delegated with the payers, the enrollment process can take 90–120 days for commercial payers. I would like to offer a solution to this timeframe, and you probably are reading this article hoping I will have one, but currently I am not aware of any. Medicare, however, will generally take the facility effective date.
One way to speed up the enrollment process is for your facility to obtain delegated credentialing contracts with the payers. Being delegated means that the payers will accept your credentials committee date as their enrollment date for your providers. This is another reason why it is so important for enrollment and credentialing to work together.
When an enrollment application is submitted to a payer, that payer reviews the application, obtains the references and all the other required information, and that information is submitted to their review committee. This committee is similar to a hospital’s credentials committee. The review committee determines whether or not to allow the provider to join their panel of providers and see their patients. This is part of what takes so long for the facility to obtain an enrollment effective date. A delegated credentialing contract means that the payer is delegating all of that responsibility to your facility.
Most if not all payers are accredited through the National Committee for Quality Assurance (NCQA). In qualifying for delegation, a facility must prove that their credentialing process meets the NCQA standards. That means all of your policies and procedures are reviewed against these standards, and your credentialing process is audited by the payers once a year. There are many, many elements reviewed during the annual audit, including Medicare and Medicaid sanctions, Medicare opt out list, review of patient complaints by provider, and all of the standard items. Upon completion of the audit process, the facility is issued a report. If any of the elements were not met, a corrective action plan (CAP) is issued with a timeframe for completing the work. At our facility, we have found the payers easy to work with and willing to share best practices to help us bring our program into compliance. Once delegation is granted, a spreadsheet is submitted to the payers at agreed-upon intervals during the year. The spreadsheet includes the hospital’s credentialing committee date, and the payer accepts this date as their enrollment date. I want to add a funny note here, and those of you familiar with the delegated spreadsheet will know what I am talking about. When my medical staff office was trying to show the value of delegated credentialing to the organization, we printed out the spreadsheet, my CMO measured it, and it was over 12-feet long. That is a lot of information that we are collecting and monitoring for every provider.
I want to thank all of those who work in payer enrollment. Until a few years ago, I had no idea the importance of the work they do. This is a job that frequently goes unnoticed until claims are returned. Because a provider is not enrolled, it is the easiest point in the revenue cycle to blame for written-off claims. To those who enjoy and are good at this work, I applaud you.
This feature appeared in the Quarter 2 2020 issue of Synergy.
Lisa Goodwin, BS, CPCS, CPMSM, is the director, medical staff services, at Kootenai Health in Coeur d’Alene, Idaho. She currently is serving as a director at large on the NAMSS Board.