What are some common provider enrollment oversights that can result in lost revenue?

Larry DeHoyos, CPCS, PESC, managing owner of LD Consulting Services: Common oversights which can lead to lost revenue [are] updating personal profiles, CAQH management, and a fully up-to-date National Plan and Provider Enumeration System (NPPES) profile. All too often residents or multispecialty groups and providers do not have current taxonomy codes, addresses, and/or identification numbers within their National Provider Identifier (NPI) registry record. Many health plans and government payers use this information to verify/confirm specialty payments in claims. Additionally, not educating your organization on the enrollment process and time needed to fully enroll a new practitioner. When there is less than adequate time, a practitioner either cannot start on time or does not have enough plan participation to fill their day and [ends] up providing services for free. Their revenue is not collectible if they were not given an effective date on or before the date of service.

Yesenia Servin, CPMSM, PESC, payer enrollment lead at Team Med Global Healthcare Consulting: One of the biggest misses has been the lack of NPPES profile review. As part of the process, enrollment specialists must review the details in the organization’s and individual’s NPI registration record. If the NPPES record does not reflect current data, this can delay the network application process, and in instances where the provider is already enrolled, the inaccurate data can result in denied claims! Denied claims = revenue loss.

Editor's note: DeHoyos and Servin will present the session Payer Enrollment Oversights at the 2023 National Provider Enrollment Forum, August 7-8, in Oak Brook, Illinois. For more information about the event, click here.