What Is the Process of Getting Credentialed with Medical Insurance Companies?

Nov 30, 2020 | Credentialing, Enrollment, Network Management, Provider Management

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The process of getting credentialed with medical insurance companies is also known as provider enrollment and is the first step of the process for inclusion into payment panels. While the process can be time-intensive, provider enrollment is the only way a healthcare provider organization can become an in-network provider and be paid by insurance companies.

Although enrollment requirements differ among payers, these steps will get you started. Don’t sleep on the process; getting enrolled and credentialed with an insurance company can take anywhere from 90 to 150 days. Missteps or postponement can cause cash flow delays and scheduling issues for your healthcare organization.

The first step to provider enrollment is credentialing. Here are the steps to keep in mind when undergoing credentialing:

  1. Be prepared: You should have your NPI number readily available and be fully licensed and in good standing in the state in which you intend to provide services.
  2. Submit a participation request to the health plan using their application process: “Join network” should be a button or link on your insurance company’s website.
  3. Panel determination: Once the health plan receives your application, they will perform a credentials verification across a multitude of databases using Primary Source Verifications. Once verification is complete, their credentialing file will go to the Credentialing Committee for approval. During these phases, you should receive a reference number to check your enrollment status. Often this is the most time-sensitive piece of the process as your credentials must be screened and verified against a multitude of federal and state databases. If the provider’s credentials are expired or ineligible, it will take longer.

Once the Credentialing Process Is Complete

Once the credentialing process is complete, the second step of provider enrollment is contracting with the insurance networks. The contracting process is the agreement that you will make with insurance companies. Contracting is separate from credentialing and is drafted by a contracting representative with whom you will review the language of the contract, discuss reimbursement rates, and all the details and responsibilities of participation. Your agreement will be mailed to you for review and a signature. It is critical to thoroughly review the fee schedule. If the fee schedule is not included in your agreement, you may request it.

Once your contract is signed and returned to the payer, you will be designated an effective date and provider number in your letter of participation. After you receive your letter of participation, your organization should ensure that the billing system is updated to begin receiving claim reimbursement. This part of the process may take 30-45 days, so the faster you update your billing system, the quicker your healthcare organization will be reimbursed.

The In-Network Billing Process 

Once your organization is enrolled in-network, your healthcare organization should establish a process for billing your health plan for services. By establishing a routine process, your organization can avoid costly delays.

Streamline collections by:

  1. Verifying patients’ insurance information before they come into the office
  2. Make sure that the payment is eligible for the service provided
  3. Collect copayment. Routine copays cannot be waived as per the Anti-Kickback Statute and False Claims Act.
  4. Submit claims in a timely manner
  5. Bill secondary payers in a timely manner
  6. Analyze and recognize patterns in denials to identify errors

How Verisys Can Help

In addition to verifying and credentialing healthcare providers and ensuring that providers’ credentials are up-to-date, administrators must also coordinate provider enrollment with each payer according to their requirements.

Verisys can relieve some of that burden by streamlining and expediting the credentials verification process. With Verisys’ access to thousands of primary source databases, verification and monitoring of your providers and can be assured for proper reimbursement on services provided by verified providers. FACIS, the gold standard in provider credentialing, can be used to continuously monitor all hospital employees and staff and can be used to search for any adverse actions, exclusions, sanctions, and restrictions. With automated monitoring technology like FACIS, your organization and your payers can be confident in enrolling verified providers who will meet your level of quality care.

Verisys can assist hospital administrators with the enrollment process of their providers with payers and insurance companies by providing reassurance to health plans that the providers are being continuously monitored. Hospital administrators lack the time and resources to complete all of these processes with multiple payers during the open enrollment period. Verisys can streamline the credentialing processes to help your organization get confidently enrolled within the open enrollment deadline.

Although the process of provider enrollment can be time-consuming and overwhelming, it is in place to ensure patient safety and quality care. In order to continue providing the highest standard of care with confidence, leverage Verisys’ provider data technology to streamline provider enrollment.

Juliette Willard Written by Juliette Willard
Healthcare Communications Specialist
Being creative is my passion! Writer. Painter. Problem Solver. Optimist.
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