Submitting accurate and required supporting provider information and documentation impacts cash flow.  The goal is to have the provider(s) enrolled in as little time as possible, and once enrolled, to properly maintain the provider’s participation status with the insurance carriers and hospitals.

Due to its very nature, Provider Enrollment’s maintenance and use of providers’ information and documents means providers must entrust some of their practice information, as well as their personal information, to a third party—the Provider Enrollment staff who is working on their behalf to enroll and maintain enrollment for the providers.  It’s essential for providers to quickly furnish as much of the requested information and documentation to their Provider Enrollment staff.  It’s equally essential for the Provider Enrollment staff to accurately and completely load the data into their provider database, and if applicable, billing database.

The benefits of accurate & current supporting documentation for Provider Enrollment/Credentialing requests:

• Enables the Provider Enrollment/Credentialing specialists to maintain accurate and current provider information records and provider documents
• Allows the Provider Enrollment/Credentialing specialists to efficiently execute the various insurance carriers’ and hospital affiliations’ credentialing/re-credentialing requests on the providers’ behalf
• Allows carrier and hospital credentialing entities to have the necessary information and documents to perform their verification/credentialing processes
• Helps accelerate the credentialing/re-credentialing processes, which in turn helps to accelerate the approval process

Attention to detail is essential and appropriate applications need to be prepared and routed to the provider to review, update and sign.

Several insurance carriers and hospitals have recently begun incorporating the use of online application preparation and submission processes.  These processes aren’t quite completely paperless, however, and original provider signatures are still required.  While this means forms still need to be printed and signed by the provider, the modified forms that need to accompany the online applications are usually minimal.

It’s All In The Details…
There’s a litany of items a provider may be asked to furnish—copies of their undergraduate & medical school degrees; internship, residency and/or fellowship certificates; medical licenses, board certifications, NPI user name and password, etc.  If a provider is applying for hospital privileges for the first time, obtaining documentation of case activity which support the requested privileges is yet another item for the provider to furnish.

For providers who are just starting their medical practices, having someone take care of their enrollments is a welcomed benefit, and they may be more willing to provide the requested information and documents without hesitation.  Providers who have been in practice, and may be joining a new group practice, may be more resistant to handing over their information and copies of their documents.  Perhaps their previous practice didn’t require them to produce a copy of their DD214 or TB test results.  Not all provider groups are contracted with the same set of insurance carriers, and while most insurance carriers use similar required information, some may ask for a unique item that may be required to complete that particular insurance carrier’s credentialing.   It’s imperative to acknowledge any concerns the provider may have, explain what the information is being used for, and assure them their information is used on an “as needed” basis for their enrollments.

Unique provider enrollment update requests,  such as a name change request due to marriage or divorce, requires copies of documents referencing the provider’s new name. Documents required are: an updated medical license, the provider’s marriage certificate, divorce decree, driver’s license, and an updated Social Security card.

Going paperless often means unique caveats come into play. For example, Medicare recently rolled out the use of their online application process via their PECOS (“Provider Enrollment, Chain, and Ownership System”) database.  In order to use PECOS to enroll a provider with Medicare, the Provider Enrollment staff must use the provider’s NPI username and password to access PECOS to create the online enrollment application.  Many times, a provider is not aware of that information, and there may be a delay until the provider is able to get a valid NPI username and password to their Provide Enrollment staff to use to create the Medicare application. Once the online enrollment application is created, specific signature forms are generated and must be printed and signed by the provider.  While these forms are significantly minimal in size as compared to the Medicare paper applications, they are specific to the provider’s created online enrollment application and cannot be used for another provider’s PECOS enrollment.

CAQH (“Council on Affordable Quality Healthcare”) is an online provider profile used by a growing number of insurance carriers, such as Aetna, CIGNA HUMANA & United Health Care, and hospitals in lieu of their own unique paper credentialing/re-credentialing applications.   Basic supporting documents such as current malpractice insurance coverage, medical licensure and DEA documents, as well as the required signed attestation form, are uploaded to the CAQH profile, and is re-attested every 120 days by the Provider Enrollment staff.  If a credentialing entity deems it necessary, the Provider Enrollment staff will also send additional requested information to the credentialing entity regarding information or documents not found on the provider’s CAQH profile. A re-attestation request from CAQH must be completed with the same attention to detail, and with a shorter turnaround time of 15 days.

Maybe it’s in the Clouds…
A vital tool for efficient Provider Enrollment management is a sound virtual storage database to house copies of submitted enrollments/credentialing applications, as well as documentation of participation approval letters and email confirmations from the providers’ contractual insurance carriers and hospitals.  A documents management database, such as Fortis, enables quick and efficient storing and filing of provider documents and also has the capability of allowing a user to export a PDF copy of any document that may be needed for electronic submission.  The trees like it too.

There are a number of credentialing software available which help maintain the provider’s demographics and practice information; produce the necessary applications containing the provider’s information to use for provider enrollment; as well as generate basic reports, such as medical license or DEA expiration dates, and provider rosters.

While credentialing and provider enrollment tasks are essential to cash flow within the practice, it never ceases to amaze me how many errors in this process continue to plague practices.  Get it right…..get it right the first time………

This article written by Pauline Blasingame, Provider Enrollment, MedPro Solutions