Provider Enrollment

Core Competency Case Study: Provider Enrollment

By Merrilee Severino, CPC, CRC, CMMP, CMP

In 2021, I was employed full-time by CLA (Clifton Larson Allen) as a Senior Consultant in Revenue Cycle. I have 30 years experience in Revenue Cycle including physician/provider credentialing and payer enrollment. I was assigned to a client to assist them with implementation of their new credentialing software as I have used it for my own business, "Your Business Medic", for years. Prior to this assignment, I had never been exposed to delegated credentialing and had not heard of NAMSS. Before starting on the project, I conducted several searches for information on delegated credentialing and quickly discovered NAMSS as a valuable resource.  

I really enjoyed my work on this client and I was blown away by the complexity of delegated credentialing vs. direct enrollment. I was so captivated by the amount of knowledge I was gaining that when the project was coming to an end I applied for the position. As part of the employment contract, they added that I must obtain my CPCS within a year. I immediately embraced everything I could get my hands on in NAMSS. I joined the Facebook page and immediately began networking and participating. I loved the free webinars each month. I purchased the study guide and also joined two study groups.  I made friends quickly.  I had belonged to other national organizations in the past for Coding as well as Practice Management, but I was really impressed with how friendly my fellow MSPs were.  

I joined the Membership Committee and also the Provider Enrollment Task Force. I know that by participating with these groups, I was able to gain some amazing relationships with brilliant professionals in the field. While planning our sessions, I learned so much from working with these experts. There was not a single time that I felt I could not ask a question and I never felt that they would think less of me if I did not understand something they were discussing.  Everyone was so willing to share.  

I think that my participation in all of these things really helped me to pass my CPCS. I also felt more confident in my approach with payers as I was still learning my system. The most valuable lesson I learned was that it was ok to push back and ask the payer to make concessions. I had felt like I was being reactive vs. proactive for most of my enrollments (we are delegated with 19 plans).  I gained confidence as I approached our payers and I was able to get 18 out of 19 to now accept the same format! This was a game-changer for me.  

What I am hoping for now through my alliance with NAMSS is to bring about change to the acknowledgment process for effective enrollment. With direct enrollment, it is normal to receive notification from a payer that the provider was enrolled and given an effective date. With delegated credentialing, it is pre-determined that the effective date will be either their approval date or start date (some have different dates, but very few).  Right now, I have to go to websites or send email messages to receive an actual confirmation.  I would love to be part of the movement that is able to get payers to send an actual acknowledgement or confirmation of loading.  I would not be able to do this alone, but I am hoping that through my membership with NAMSS and participating and suggesting, that we can bring about industry wide change.