Provider enrollment: An introduction to the field

The following is the first in a series of articles focused on the provider enrollment field. Both newcomers to the field and seasoned professionals should check back each month for tips, tools, and best practices. In creating this series, Medical Staff Briefing collaborated with industry veteran Dina Solis, PESC. Solis can be reached at dina@sonomacredentialing.com or via Sonoma Credentialing Services’ website at https://sonomacredentialing.com.

For numerous MSPs, provider enrollment is becoming an increasingly familiar topic. According to the 2018 MSP Salary Survey Report, approximately 30% of respondents who work in the medical staff services department also handle provider enrollment. Although that means 70% of MSPs do not currently deal with provider enrollment, it is likely that they may in the future. Therefore, Medical Staff Briefing sought to provide education on provider enrollment that could help both those already in the field and MSPs who may eventually take on enrollment responsibilities.

To provide this education, Medical Staff Briefing sat down with provider enrollment expert Dina Solis, PESC, owner and principal consultant of Sonoma Credentialing Services, a San Francisco Bay Area consulting business that specializes in helping healthcare providers across the United States become enrolled, contracted, and credentialed with governmental and private payer health insurance plans. With nearly 20 years of experience in the industry, Solis speaks at conferences, presents webinars, and writes online content about provider enrollment processes and best practices. 

This first article provides a comprehensive introduction to the provider enrollment field and serves as a great starting point for anyone who has just entered the industry.

The basics of enrollment

As defined by Solis, provider enrollment is “the process that healthcare providers use to request network participation with health insurance plans/payers so they can be reimbursed for services rendered to patients.”

In other words, provider enrollment allows organizations to be reimbursed by different insurers for the services their practitioners provide. If the practitioners are not enrolled with the insurers, the insurers will not pay the organization where the practitioners provide services.

Who specifically enrolls the providers with payers varies from organization to organization, explains Solis. However, she notes, “Enrollment is typically performed by an enrollment or credentialing specialist who can report under departments such as credentialing, CVO, medical staff office, finance, executive administration, reimbursement, revenue cycle management, contracting, or compliance.” Throughout her career in the field, Solis has reported under almost all of these departments.   

All medical practitioners seeking reimbursement from payers, whether government or commercial, must be enrolled with that payer. Therefore, any organization providing the services of a practitioner must perform (or outsource) the enrollment process. Solis offers the following examples of providers who generally are enrolled as part of the process:

• Physicians
• Nurse practitioners, physician assistants, and other advanced practice professionals
• Behavioral and mental health providers
• Diagnostic, therapeutic, and custodial providers such as those working in sleep testing, radiology, therapy, home health, hospice, and skilled nursing

She also lists the following organizations that typically perform provider enrollment:

• Medical groups
• Hospitals and medical centers
• Ancillary services employing diagnostic, therapeutic, and custodial providers
• Third-party and outsourced service providers such as credentials verification organizations and enrollment consulting services

While neither of these lists are exhaustive, they present a general idea of the scope of the provider enrollment industry.

Ultimately, the provider enrollment process plays an extremely important role in ensuring that organizations are reimbursed for the care their practitioners provide patients. Therefore, it is essential that the enrollment process is done properly.

“Proper enrollment means that the process is carried out in a timely and accurate manner and that consistent communication is maintained among stakeholders,” Solis explains. If an organization is providing patient services and not receiving reimbursement in a timely manner or even at all, it is detrimental to the organization’s financial wellness. Therefore, a great deal depends on a complete and proper enrollment process.

The provider enrollment process

The provider enrollment process is multifaceted and therefore most easily understood in parts. Solis prefers to break it down into two phases: pre-enrollment, which covers the tasks that are performed before and during the enrollment process, and post-enrollment, which involves the tasks that are performed after the enrollment process has been completed.

However, Solis cautions, “Please keep in mind that these steps can vary greatly by payer, and that this is in no way a process for all payers, but rather a high-level overview of the fundamental steps.”

In collaboration with Solis, Medical Staff Briefing provides the following as an outline of the enrollment process.

Pre-enrollment phase

Step 1: Enrollment professionals must first determine which payers they wish to enroll the provider with. Solis points out that these payers may be predetermined by the organization or the professional may need to research which payers cover the area and are currently accepting new providers. Enrollment professionals should also seek information from payers regarding the process, time frame, and any special requirements.

Step 2: The enrollment professional must collect all required information from the provider and prepare any necessary documents. According to Solis, this may include demographic information, credentialing documents, attestations, disclosure questions, fingerprints, and the application fee.

Step 3: Some payers might require a letter of interest, especially if they only accept a few providers for a given provider type. In such cases, Solis recommends using the letter of interest “to sell your provider to the payer by including basic demographics as well as information that highlights any special attributes the provider offers as value to the payer.”

Step 4: Complete the application form and submit it to the payer. According to Solis, enrollment professionals need to be aware that some provider types require unique or additional forms. Additionally, enrollment professionals should be sure to submit any required attachments and to request tracking information for the application’s status.

Step 5: Monitor the status of the application and follow up as necessary. Solis adds, “This can be tricky because payers are oftentimes slow to respond to status inquiries.” Upon receiving approval, the enrollment professional should be sure to obtain proof of enrollment that includes the effective date.

Step 6: Solis urges professionals not to immediately accept a network denial. “If your provider is denied network participation, use your excellent communication skills to ask for a second-level appeal, and submit additional information to the payer to clarify exactly what your provider does and what value he or she presents to the payer,” she advises. Additionally, if the provider is still denied, she suggests asking when the payer reevaluates their provider network and resubmitting an application then.

Post-enrollment phase

Step 1: Upon the provider’s approval, be sure to obtain proof of enrollment. While this is the same as step 5 of the pre-enrollment phase, it is so essential that it bears repeating here. Solis explains, “Some payers don’t provide or are late in providing the welcome letter. Keep on them, and if you still have trouble, don’t hesitate to ask for a supervisor to escalate the issue to.”

Step 2: Inform stakeholders of the new provider’s enrollment status. Solis states that this may include “informing the provider, billing or revenue cycle management department, contracting department, information technology department, and/or finance department. You might help set up electronic funds transfer agreements, electronic remittance advice, electronic data interchange, or web portal administration.” All of these steps will help implement the provider’s new enrollment status within the organization.

Step 3: Keep copies of all documentation as necessary, such as the agreement, welcome letter, reimbursement rates, payer correspondence, billing manual, and claims information. Solis recommends scanning any paper documents into your organization’s database or software for safekeeping.

Step 4: An important ongoing responsibility of the enrollment professional is maintaining enrollment compliance with the payer. According to Solis, this can include responding to requests for revalidation, submitting nonexpired licensure and/or insurance certificates, and reporting any changes in the provider’s information.

Because step 4 is ongoing, it is never truly complete, and therefore the provider enrollment process also remains ongoing.

Until next time

Stay tuned for next month’s article, where Medical Staff Briefing will share Solis’ tips for overcoming common challenges in the field and highlight helpful resources for those currently working in the provider enrollment community. In the mean time, see Solis' 10 tips for provider enrollment professionals.