Provider Enrollment in credentialing services Explained

January 17, 2023

Credentialing and contracting are processes you must go through to participate with insurance networks and receive in-network reimbursement for your practice's medical care service. The process is known as provider enrollment.

There are too many manuals and varying procedures involved in the credentialing process for providers with payers, such as filling out applications, responding to payer questions, and following up to ensure the credentialing request is completed promptly and accurately. 

Therefore, it is advisable to use enrolling and credentialing services to perform this tolling and time-consuming task. Credentialing services help keep your data up to date. 

What is Provider Credentialing? 

Provider credentialing is when an insurance carrier formally assesses a provider's qualifications, licenses, and competency to admit them into their payer network.

Provider credentialing is critical in improving your revenue cycle as it gives patients the ability to use their insurance cards to pay their medical bills. Provider enrollment enables you to get reimbursed by insurance companies for the healthcare service you provide.

Therefore, it is crucial that you get credentialed and enrolled with multiple insurance panels to enable access to a broader range of patients who can use their insurance plans to receive medical care in your practice. 

Today, neglecting provider enrollment will weaken your competitive power as most prospective patients will instead employ the service of practices already enrolled with their insurance companies. 

Credentialing with a payer can be a tedious, time-consuming process that involves sorting through many documents, providing an adequate response to the payer, and closely following up with the payer on the progress of your credentialing request. 

Steps Involved in Provider Credentialing 

The procedures process of getting involved with provider credentialing consists of the following steps :

  •  Evaluation of Application: This involves filling out required forms, putting all relevant documentation in place, and identifying exceptions.  
  •  Primary Source Documentation: Practitioner/facility credentials are verified by physicians in this phase.
  •  Outbound Call Center: In this phase, the payers' database is updated, and missing documents are obtained.
  •  Make routine follow-up calls with payers: Find out the status of your credentialing requests from time to time.
  •  Data Entry: Do a data capture and link the images to your profile in the payer database.
  •  Regular maintenance of Data: Make sure your information is frequently updated by keeping up with payers' latest policies, procedures, and CAQH profile requirements. 

Provider Enrollment Procedure 

To get your practice enrolled for the services you provide, provider enrollment services ensure that payers have the necessary data to process claims for the applications are processed speedily to avoid unnecessary delays in payments. 

And if there are any potential administrative issues, they resolve them speedily, so it doesn't affect your reimbursements.

In carrying out provider enrollment, the following steps are taken; 

  • Verify your Information: Payers are contacted to confirm they have your correct details on their database before submitting your claims.
  •  Updating your Billing address: They also validate and update your practice pay-to or billing address when needed.
  •  Enrolling for electronic transactions; Four types of electronic transactions they might register you for include; Electronic Remittance Advice(ERA), Electronic Data Interchange (EDI), CSI, and Electronic Fund Transfer (EFT).

With Provider Credentialing And Enrollment Services, You Can:

  •  Get more patient referrals and get your payments from insurance processed faster.
  •  Curb leakage in revenue. 
  •  Easily keep your data with payers updated. 
  •  Avoid the stress of sorting through piles of paperwork and filling out an application form.
  •  Reduce denial rate and develop relationships with different payers.
  •  Have real-time knowledge of the status of your credentialing and enrollment transactions.

Provider credentialing and enrollment are simplified when you partner with a revenue cycle management partner who reviews and gathers documentation to determine the provider's participation in the health plan. 

Credentialing and enrollment services designed to meet insurance plan requirements eliminate the headaches of tracking applications for credentialing and enrollment.

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