What Is Provider Enrollment?

Dec 23, 2021 | Credentialing, Enrollment | 0 comments

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By Tracey Tokheim, Senior Director of Product Management at Verisys Corporation

Many healthcare providers justifiably experience confusion over the terminology surrounding provider enrollment, which is only getting more complicated with the ongoing changes in healthcare.

A common confusion is the difference between provider enrollment and provider credentialing. Provider enrollment is the application process by which a practitioner is approved to seek reimbursement from government and/or third-party payers or seek admitting privileges at a hospital. Provider credentialing is a separate process of obtaining, verifying, and assessing the qualifications of a healthcare practitioner to provide patient care services in or for a healthcare entity. While credentialing is a part of enrollment, it is only a piece of the process to qualify for reimbursement.

This article will explore the plans, processes, and pitfalls to prepare for and help healthcare organizations navigate the provider enrollment process. It includes:

  • The provider enrollment process for various government health plans
  • Steps to successful enrollment
  • Software options to ensure provider data integrity and optimized enrollment management
  • New regulatory requirements

Medicare, Medicaid, and TRICARE: How Enrollment Standards Differ

Provider enrollment in Medicare, Medicaid, TRICARE, and other government health programs all involve a lengthy process, with some variation. Each program has a separate set of standard forms that must be filled out and sent to appropriate program administrators. Here are some key items to remember:

The Medicare and Medicaid enrollment processes are very detailed, and it is critical to review the enrollment applications prior to submission. The Centers for Medicare and Medicaid Services (CMS) accepts enrollments through various 855 forms via their online portal: PECOS (Provider Enrollment, Chain, and Ownership System). You can also use PECOS to submit changes of address, reassignment benefits, discontinuation of benefits, and changes of ownership. Extensive enrollment information can be found on the CMS website.

The following items are required for enrollment in Medicare:

  • A primary place of service must be in operation
  • Banking information will be required to set up Electronic Funds Transfer (EFT) payments for your Medicare reimbursements
  • Personal details for every individual having an ownership stake in your practice must be included
  • Citizenship documents are required for providers born as non-U.S. citizens
  • The Educational Commission for Foreign Medical Graduates (ECFMG) certificate is required for providers who are educated out of the U.S.
  • Application forms must be signed correctly in every signature field

There are significant differences between the Medicare enrollment process and commercial payers. For example, you can bill Medicare 30 days prior to the date that they receive your application (also known as your “effective date”). So, if Medicare takes 60 days to complete your application, you can back bill to your effective date. In contrast, commercial payers do not honor back-billing.

TRICARE enrollment forms differentiate by state and region; these regions include TRICARE North region, TRICARE South Region, and TRICARE West region. Each region has slightly different forms and its own regional contractor.

The enrollment process requires significant time to complete, so do not wait to begin the enrollment process. Delays can cause problems with credentialing and reimbursement. Be aware of these common issues that could cause delays or denials such as:

  • Lack of Data Integrity. Is your data correct and verified by a primary source?
  • Poor Communication. Will obscure or outdated technology or language barriers make it difficult for agencies to communicate with you?
  • Limited Expertise. Do you require expertise outside of the enrollment department (e.g., IT) to successfully complete the enrollment process?
  • No Clarity in Processes. Does everyone involved in the enrollment process understand the purpose of the data and the recurring deadlines to keep enrollment up to date?

Four Tips for Successful Provider Enrollment Applications

1. Enrollment Is Undergoing a Digital Transformation

Like most healthcare processes, provider applications for enrollment have also undergone a digital transformation. According to CMS, the internet-based Provider Enrollment, Chain, and Ownership System (PECOS) now allows providers and suppliers to electronically sign Medicare enrollment applications. Individual provider applications (855-I) containing new reassignments (855-R) can be electronically signed as part of the submission process. You will be required to select the authorized official (AO) for the organization who is accepting the reassignment and enter the official’s email address. The official will then receive the email from PECOS and be required to electronically sign the application.

Similarly, Council for Affordable Quality Healthcare, Inc. (CAQH) now has an enroll hub for providers to enroll digitally. CAQH ProView allows providers to enter information free of charge into a secure central database and authorize healthcare organizations to access that information. By sharing information with electronic signatures and secure databases, providers can ensure faster application submission, resulting in an earlier effective date.

However, some forms may still require paper enrollment applications and your organization should be prepared to process both paper and electronic database applications. To prepare and keep track during this transition, organizations should define clear hand-offs, maintain a process to track and manage recredentialing due dates, maintain an expirables management system, use continuous sanctions monitoring, and implement dedicated provider directory management.

2. Application Review Is Critical 

Simple mistakes can cause denials and derail the entire process. Providers should review their applications thoroughly, and employers should watch for potential red flags. Here are the most common missteps and/or mistakes found during when reviewing applications:

  • Gaps in employment history. Explain employment history gaps. Missing information may also raise a red flag.
  • Unanswered questions or missing information. Don’t overlook small details such as dates, personal information, etc. Complete applications are critical.
  • No explanation to “Yes Affirmative” answers. If providers answer questions affirmatively, they should provide an explanation.
  • Information discrepancies. Information provided by applications and received from primary sources should be the same. Inconsistent answers are immediate red flags.
  • High number of malpractice cases. If a provider’s record shows a high number of cases, discipline by a licensing entity, or frequent moves, it may indicate a problem.
  • Vague references. Unverified references could prevent complete evaluation.
  • Cancellation or denial of liability coverage.
  • Mismatch of information from the National Practitioner Data Bank (NPDB) and other sources.

3. Delegated Credentialing Agreements Save Time

A delegated credentialing agreement is the process by which an entity responsible for credentialing creates an agreement to turn a portion of their credentialing review over to a qualified entity, allowing that entity to perform credentialing on their behalf. With a delegated credentialing agreement, health plans/payers can shave significant time off the enrollment process, enabling faster provider onboarding and reimbursement. However, a hasty delegated credentialing agreement can be disastrous. Follow these steps to thoroughly review delegated credentialing agreements:

  1. Evaluate the delegation agreement to ensure it contains the following:
    • All the required elements for compliance
    • Mutual agreement of the terms of the agreement
    • Detailed outline of all responsibilities
    • At least the minimum number of semi-annual audits
    • A process for hand-offs as the process is completed
    • A contingency plan if all obligations are not met
  1. Construct a delegation agreement
  2. Identify a pre-delegation evaluation process
  3. Define delegation oversight/annual audit process
  4. Evaluate reporting
  5. Approval of final reporting outcomes

4. Internal Communications and Processes Matter

Your team should be trained to understand the importance of provider enrollment and its impact on organizational performance and revenue. It is critical that buy-in and commitment to continued review begins with leadership and extends through the organization.

You can reduce error, minimize frustration, and avoid penalties and delays by maintaining an organized process that providers and administrators may use to track enrollment application progress. To ensure more successful enrollment applications, implement a system that will immediately identify data discrepancies and ensure data integrity. You can ensure a streamlined process for your healthcare organization by staying connected to plans and hospitals and clearly communicating to your providers the importance of data integrity and the effectiveness of established processes.

Technology Solutions to Streamline the Enrollment Process

Smaller, less complex healthcare organizations might be able to use spreadsheets to manually track the steps on a provider’s enrollment process, but larger, more complex organizations will benefit greatly by implementing technology solutions to track and manage enrollment.

Provider enrollment can be daunting and new technology can be intimidating if software implementation and integration is overly complex. Your providers should prioritize premium patient care, not processes. That’s why choosing the right technology to streamline your enrollment process is key.

Your organization’s enrollment software should integrate with today’s premium technology, empower access to the highest-quality data, and allow ultimate convenience to your provider enrollment process. Systems should also support an unlimited number of user roles with scalable fees that fit any budget so that no matter your practice or facility size, your software will fit your practice or facility’s specific needs and budget.

With changing regulations around enrollment in the last few years, it’s critical that healthcare organizations create systems that support providers with intuitive online application tools, multi-system communications matrixes with documentation and accountability, mentorship, and education. Many organizations choose to outsource all or some aspects of provider data management to a third party. Even if these services are being outsourced, it is important that your team understands and commits to data integrity processes and promotes internal communication and education.

Verisys’ configurable software meets the full range of enrollment requirements for health plans and payers including:

High-Quality Data Sources Increasingly Important with New Regulations

Regulatory and policy initiatives are increasingly addressing provider data issues across the country. As a result, recent policy and regulations reflect a growing acknowledgement of provider data challenges, specifically implications of poor-quality provider data.

For example, CAQH reported that The New York State Department of Health developed standards for submission of provider data for Medicaid, Marketplace, and commercial health plan network standards. In addition, recent rules and guidance from CMS establish provider directory requirements for Medicare Advantage, Medicaid Managed Care, and Qualified Health Plans (QHPs) to improve interoperability, address provider directory format, increase patient access to information, and change the frequency of updates.

In the past few years, over 25 states and the District of Columbia, as well as Medicare, Medicaid, the Federally Facilitated Marketplace, and the National Committee for Quality Assurance (NCQA) have released requirements to ensure accuracy of provider data and quality reporting in a health plan directory. Four of these states and Medicare Advantage require health plans to validate the data displayed in a provider directory with providers on a regular basis. It’s just a matter of time before other states adopt increased regulations around provider directory information as well.

Healthcare is changing. With increased locum tenens providers, digital transformation, the expansion of telehealth, and updated guidelines targeting the opiate epidemic, state and federal regulations around provider data are in flux. There is also increasing awareness that requirements will place a significantly higher burden on providers and healthcare facilities to be responsible for keeping providers credentialed and in good standing.

The good news is that we are here to help. With nearly 30 years of provider enrollment experience, Verisys’ enrollment management software is a proven solution. We serve the largest healthcare delivery systems in the country and are the most trusted source of accurate provider data.

Want more information on provider enrollment? View our recent webinar given by 30-year industry expert Tracey Tokheim.

If you’re looking for a partner to help your organization in provider enrollment and beyond, contact Verisys today to see how we can help you. 

Tracey Tokheim has more than 30 years of experience in provider enrollment and credentialing. As senior director of product management at Verisys Corporation, she leverages technology to help clients achieve successful outcomes. Before joining Verisys/Aperture Health, she directed credentialing at UMPhysicians, MN Credentialing Collaborative, and HealthEast.