Payor enrollment and credentialing are two crucial steps healthcare providers must complete to join health insurance networks and receive payment. These procedures make sure that providers follow quality standards and eligibility requirements set by health plans, as well as adhere to government program rules and policies.

Payor enrollment and credentialing also impact the revenue cycle management and financial success of healthcare organizations, determining payment rates, terms, and conditions of contracts with health plans. Moreover, these processes affect patient access and satisfaction, as they allow providers to serve a larger population and lower out-of-pocket costs for patients. In this article, we will explore the connection between these processes and explain how they work together.

Credentialing is the process of verifying and validating a healthcare practitioner's qualifications, competence, and performance. This crucial step ensures that only qualified professionals can provide services to patients within a healthcare organization or network. Additionally, it safeguards the organization from legal liability and regulatory penalties.

The typical credentialing process consists of several steps:

Application Submission: The practitioner submits an application to the credentialing entity (e.g., a hospital, health plan, or managed care organization), along with supporting documents like licenses, certifications, diplomas, malpractice insurance, and references. The application should contain details about the practitioner's education, training, work history, scope of practice, and any disciplinary actions or malpractice claims.

Verification and Validation: The credentialing entity verifies and validates the provided information by contacting primary sources such as licensing boards, certification bodies, educational institutions, previous employers, and peer references. They also check the practitioner's status on the National Practitioner Data Bank (NPDB) and the Office of Inspector General (OIG) exclusion list. This process ensures the information's accuracy and currency.

Credentialing Committee Review: A credentialing committee, composed of qualified and impartial members, evaluates the application and verification results. Based on their findings, they may approve, deny, defer, or limit the practitioner's privileges.

Final Approval and Notification: The credentialing entity informs the practitioner of the committee's decision in writing. If approved, the practitioner receives privileges within the organization or network for a specified period (usually two or three years). If denied, deferred, or limited, the entity provides the reasons and informs the practitioner of their rights to appeal or reapply.

Setting the Credentialing Bar

Various accrediting bodies and organizations develop credentialing standards that outline minimum requirements for practitioners. Some widely recognized credentialing standards include:

The National Committee for Quality Assurance

NCQA is a non-profit, privately-run organization that evaluates and accredits various healthcare entities on their quality measures and standards. These include health plans, physician organizations, ACOs, PCMHs, and telehealth providers. NCQA offers credentialing programs for each of these entities.

NCQA's credentialing standards cover a wide range of topics, including the content and timing of applications, the sources and methods used for verification, the composition and functions of credentialing committees, the frequency and criteria for re-credentialing, oversight, and monitoring of delegated functions, and the appeals process.

The committee is devoted to ensuring that healthcare organizations achieve the highest quality and performance requirements. Its accreditation processes provide an impartial assessment of an organization's capacity to provide excellent healthcare services to its patients.

Utilization Review Accreditation Commission

URAC is a nonprofit organization that evaluates and accredits healthcare entities based on their compliance with quality standards and best practices. It offers various accreditation programs tailored to different types of healthcare entities, such as health plans, provider organizations, pharmacies, telehealth providers, and much more.

URAC's accreditation programs cover a wide range of healthcare areas, including workers’ compensation utilization management, disease management, health call centers, health websites, wellness programs, health risk assessment programs, chronic condition management programs, and others.

Commision’s credentialing standards ensure that healthcare entities meet the highest standards of quality, performance, and compliance. These standards cover areas such as application content and timeliness, ensuring that healthcare entities are held accountable for meeting strict guidelines and best practices.

The Joint Commission

The Joint Commission is another nonprofit organization that focuses on accrediting and certifying healthcare organizations and programs based on their adherence to the highest quality and safety standards. This organization offers a variety of accreditation and certification programs that are tailored to hospitals, ambulatory care centers, nursing care centers, laboratory services, and much more. The programs cover areas such as advanced disease-specific care, integrated care, patient blood management, perinatal care, primary care medical home, and telehealth certification programs, to name a few.

The Commission's credentialing standards are rigorous and comprehensive, covering areas such as application content and timeliness, verification sources and methods, credentialing committee composition and functions, re-credentialing frequency and criteria, delegation oversight and monitoring, and appeals process. These standards ensure that healthcare entities meet the highest standards of quality and safety and that they continually strive for excellence.

The process of enrolling with payors can be complicated and time-consuming. To help you navigate this process, we have broke down the key steps involved:

1. Obtaining a National Provider Identifier (NPI)

A National Provider Identifier (NPI) is a unique 10-digit identification number assigned to each healthcare provider by the Centers for Medicare and Medicaid Services (CMS). The NPI is used to identify the provider in standard transactions, such as claims and eligibility inquiries. To obtain an NPI, the provider must apply online through the National Plan and Provider Enumeration System (NPPES) or submit a paper application form.

2. Credentialing with Payors

Credentialing is required by most payors to ensure that the provider meets their standards of quality and compliance. To initiate credentialing, the provider must submit a credentialing application and supporting documents to each payor they wish to enroll with. The process may take several weeks or months, depending on the payor’s policies and procedures.

3. Submitting Enrollment Applications

Enrollment is contingent on successful credentialing and acceptance of the payor’s terms and conditions. To enroll with a payor, the provider must submit an enrollment application and any additional forms or documents required by the payor. The enrollment application may be submitted online, by mail, fax, or email, depending on the payor’s preference.

4. Tracking and Monitoring Enrollment Status

The provider should follow up regularly and respond promptly to any requests for additional information or clarification from the payor. The enrollment status may be checked online, by phone, or by email, depending on the payor’s communication methods.

5. Maintaining and Updating Information

Providers should notify the payor of any changes in their practice location, contact information, services offered, or credentialing status. It is important to renew the enrollments periodically, as required by the payor’s policies and procedures. Maintaining and updating information is essential to ensure accurate and timely reimbursements.

Credentialing is a must for all providers who want to participate in federal health programs or work in accredited healthcare institutions. It also plays a vital role in payor enrollment, as ensures that providers meet the quality and safety standards of health plans. Simply put, without credentialing, providers cannot enroll in payor networks and so, are unable to receive payment for their services.

Let’s take a closer look at the connection between the two:

Government Programs: These include federal programs such as Medicare, Medicaid, Veterans' Administration, and Workers' Compensation, as well as state programs such as CHIP and Medi-Cal. These programs typically have fixed and standardized credentialing requirements that are set by government agencies and may not be negotiable.

It's also important to note that providers must obtain a National Provider Identifier (NPI) number by enrolling with the Centers for Medicare & Medicaid Services (CMS) through either the Provider Enrollment, Chain and Ownership System (PECOS) or the National Plan and Provider Enumeration System (NPPES). Depending on the program, providers may also need to undergo site visits or audits by CMS or its contractors to verify their credentials and compliance with program standards.

Commercial Insurance Companies: Private health insurance companies provide a variety of plans for individuals, families, employers, and beneficiaries of Medicare. Humana, Aetna, Cigna, UnitedHealthcare, Anthem, and Blue Cross Blue Shield are a few examples. These organizations may have varying credentialing requirements for various plans or products, such as HMOs, PPOs, EPOs, and POSs.

These documents include copies of the license, DEA certificate (if applicable), malpractice insurance, and board certification (if applicable). In addition, providers must submit their CV, a signed provider agreement, and any other supporting documents required by the payor.

Providers must also complete the CAQH online application and authorize the company to access the profile, which is used by many payors for credentialing and re-credentialing purposes.

Third-Party Administrators (TPAs): These are entities that contract with ERISA plans or self-funded employer plans to administer the health plans, including claims adjudication and payment, utilization management, physician contracting, and other administrative functions necessary for plan operations. Examples are UMR, Meritain Health, HealthSmart, and ASR Health Benefits. These entities may have their own credentialing requirements or follow the requirements of the plan sponsor or the network they use. Required documents are generally the same as in the cases above.

Challenges and Common Errors in the Credentialing and Payor Enrollment Process

Incomplete or Inaccurate Applications

One of the most common challenges and errors in the credentialing and payor enrollment process is submitting incomplete or inaccurate applications. Providers need to provide at least 15 data elements per professional—contact information, NPIs, and primary practice locations.

It is easy to miss some of the information, provide outdated or incorrect information, or fail to attach the required documentation. Which results in delays, denials, or rejections of credentialing and payor enrollment applications.

Learn more about The Power of Accurate Provider Data in Credentialing & Enrollment

Lapsed Credentials and Re-credentialing

Another common challenge is letting credentials lapse or forgetting to re-credential. All credentials have an expiration date, which requires providers to repeat the credentialing process every 1 to 3 years.

However, sometimes providers may not be aware of their credential expiration dates, or they may not have enough time or resources to complete the re-credentialing process. This can result in losing their eligibility to participate in health plan networks and receive reimbursement for their services.

Failure to Update Information

Providers may change their contact information, practice locations, licensure status, malpractice history, or other credentials over time. Sometimes they can forget to inform the credentialing specialists of these changes promptly or accurately.

This can result in discrepancies between the provider's information and the information on file with the payers or regulatory agencies. Which can also result in delays, denials, or termination of credentialing and payor enrollment applications.

Credentialing and Enrollment Delays

The credentialing and payor enrollment process can take anywhere from 90 to 180 days for each provider. The process can take longer due to various factors, such as incomplete or inaccurate applications, lapsed credentials, failure to update information, payer-specific criteria, and process, or backlog of applications.

This can result in providers not being able to start providing services or receiving payment for their services on time. Which can lead to lost revenue and patient dissatisfaction.

Best Practices for Navigating the Credentialing and Payor Enrollment Process

Developing a Systematic Approach

By adopting a systematic approach, providers and credentialing and enrollment specialists can proactively plan, organize, and track the application process. This approach can help prevent missing important details or deadlines and ensure effective communication between all parties involved, including payers and regulatory agencies.

For instance, a checklist can be created to ensure all necessary data and documents are obtained from each provider and payer. Utilizing a calendar or reminder system can ensure that credential expiration dates and re-credentialing deadlines are not overlooked. A spreadsheet or database can be used to store and update provider information, while roles and responsibilities can be assigned for each step of the process.

Regularly Reviewing and Updating Information

By regularly reviewing and updating provider data, credentialing specialists can ensure that all the information is up-to-date, accurate, and complete. This can help prevent delays, rejections, or denials of applications that could result from incomplete or incorrect data.

Moreover, regularly reviewing and updating provider information allows credentialing specialists to keep track of credential expiration dates and to begin the re-credentialing process in a timely manner. For instance, they may verify provider information from primary sources once a year, inform payers of any changes in provider data within 30 days, submit re-credentialing applications at least 90 days before credentials expire, and perform regular checks for errors or discrepancies in provider data.

Leveraging Technology

Another helpful tip for navigating the credentialing and payor enrollment process is to utilize technology to simplify and automate the process. By leveraging technology, providers and credentialing and enrollment specialists can collect, verify, submit, and update information and documentation electronically, which is faster and more efficient than traditional paper-based methods. Technology can also help to monitor the status of applications in real-time, receive alerts or notifications of any issues or changes, and communicate with payers or regulatory agencies online. This reduces errors, delays, and denials by ensuring that the applications are consistent, accurate, and compliant with payer-specific criteria and processes.

Using technology may include employing credentialing software, electronic data interchange (EDI), or cloud-based platforms that provide credentialing and payor enrollment solutions. According to a 2019 report by Madaket Health, automating the payer enrollment process using technology can reduce administrative costs by up to 80%, cut approval times by up to 50%, and increase revenue by up to 10% by enabling faster participation in payer networks.

Credentialing Software

Credentialing software is an efficient tool that can help healthcare providers and credentialing and enrollment specialists manage the credentialing process effectively. Such software allows to store, manage, update, verify, submit, track, and report provider data in a centralized database that can be accessed online from any device. With credentialing software, providers can automate sending reminders or alerts of expiration dates or missing information.

Credsy is an example of such software. It combines automation and expert compliance management, which helps to minimize manual work and errors, assure regulatory compliance, and provide a unified data hub for centralizing provider data across different states or organizations, ensuring consistency, accuracy, and up-to-date information.

Credsy also provides secure messaging and document-sharing features for seamless communication among stakeholders, real-time tracking, and automated document processing to minimize errors and inaccuracies and lower the risk of non-compliance.

Electronic Data Interchange (EDI)

EDI is a method of exchanging data electronically between different parties, such as providers, payers, or regulatory agencies. It can help to submit, receive, process, and confirm the payor enrollment applications in a standardized, secure, and fast way.

There are several top electronic data interchange options available, including IBM Sterling B2B Integrator, Anypoint Platform, Microsoft BizTalk, and TrueCommerce EDI Solutions.

The Future of Credentialing and Payor Enrollment

The credentialing and payor enrollment process is constantly evolving and adapting to the changing needs and expectations of providers, payers, and patients. Some of the emerging trends and innovations that are shaping the future:

  • Telehealth and virtual care: The COVID-19 pandemic has accelerated the adoption and expansion of telehealth and virtual care services, which offer convenience, accessibility, and affordability for patients and providers. However, telehealth and virtual care also pose new challenges and opportunities for credentialing and payor enrollment, such as ensuring compliance with state licensure laws, meeting payer-specific criteria for telehealth reimbursement, and verifying provider identity and location.

  • Blockchain technology: Blockchain technology has the potential to transform the credentialing and payor enrollment process by enabling faster, cheaper, and more accurate data exchange, verification, and validation among providers, payers, and regulatory agencies.

  • Artificial intelligence (AI) and machine learning (ML): Technologies that can analyze large amounts of data and learn from patterns and trends can help improve the efficiency and effectiveness of the credentialing and payor enrollment process by automating repetitive tasks, detecting errors or anomalies, predicting outcomes or risks, and providing insights or recommendations.

FAQs about Credentialing and Payor Enrollment

How long does the credentialing and payor enrollment process take?

The time it takes to complete the credentialing and payor enrollment process can vary depending on various factors, including the number and type of payors, the accuracy and completeness of the applications, the specific criteria and process of each payor, and the availability of primary source verification. Typically, the credentialing and payor enrollment process can take between 90 to 180 days for each provider. However, some payors may take longer than others to review and approve the applications.

What are the consequences of not being credentialed or enrolled with a payor?

The consequences can include losing revenue due to the inability to receive reimbursement for services provided to patients covered by that payor. It can also result in a loss of patients who may prefer to see providers who are in-network or participating in their health plan. Additionally, not being credentialed or enrolled with a payor can damage the reputation and credibility of the provider or organization, resulting in lower ratings, referrals, and contracts.

Can I enroll with multiple payors simultaneously?

Yes, providers can enroll with multiple payors simultaneously, as long as they meet the requirements and follow the process of each payor. However, enrolling with multiple payors simultaneously can also increase the complexity and workload of the credentialing and payor enrollment process.

How often should I update my credentialing and enrollment information?

It is important for providers to update their credentialing and enrollment information whenever there are changes in their status or information, such as contact information, practice locations, licensure status, malpractice history, or other credentials. Additionally, providers should update their credentialing and enrollment information when they need to re-credential or re-enroll with a payor, which is typically required every 1 to 3 years.

What are the costs associated with credentialing and payor enrollment?

The costs associated with credentialing and payor enrollment can vary depending on the type and number of payors, the type and number of providers, the method and frequency of credentialing and payor enrollment, and the use of credentialing and enrollment specialists or organizations. Some payors may charge application fees for credentialing or payor enrollment, which can range from $25 to $200 per provider per application. Additionally, some primary sources may charge verification fees for providing information or documentation about provider credentials, which can range from $5 to $50 per provider per verification.

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