Payor Enrollment and Credentialing: Figuring out the Connection and Exploring the Process

Payor enrollment and credentialing are critical steps that healthcare providers must complete to join health insurance organizations and receive payments. These processes ensure that providers meet quality standards and eligibility requirements set by health plans and comply with government program regulations and policies.

These processes also significantly impact healthcare organizations' revenue cycle management and financial success by determining payment rates, contract terms, and conditions with health plans. Additionally, they affect patient access and satisfaction, enabling providers to serve a larger population and reduce out-of-pocket costs for patients. This article will explore the relationship between these processes and explain how they work together.

Understanding the Credentialing Journey

Provider credentialing is the process of verifying and validating a healthcare professional’s qualifications, skills, and performance. This crucial step ensures that only the most qualified professionals provide services to patients within a healthcare organization. It also protects the organization from legal liability and regulatory penalties.

The typical provider credentialing process includes several stages:

1. Application Submission: The provider submits an application to the credentialing entity (such as a hospital, health plan, or managed care organization) along with supporting documents like licenses, certifications, diplomas, malpractice insurance, and references. The application must include details about the professional’s education, training, work history, scope of practice, and any disciplinary actions or malpractice claims.
2. Verification and Validation: The credentialing entity verifies and validates the provided information by contacting primary sources, such as licensing boards, accreditation bodies, educational institutions, previous employers, and peer references. They also check the professional’s status in the National Practitioner Data Bank (NPDB) and the Office of Inspector General (OIG) exclusion list. This process ensures the accuracy and legitimacy of the information.
3. Credentialing Committee Review: A credentialing committee consisting of qualified and impartial members reviews the application and verification results. Based on their findings, they may approve, deny, defer, or restrict the provider’s privileges.
4. Final Approval and Notification: The credentialing entity informs the provider of the committee’s decision in writing. If approved, the provider receives privileges within the organization or network for a specified period (usually two to three years). If denied, deferred, or restricted, the entity provides the reasons and informs the provider of their rights to appeal or reapply.

Establishing Credentialing Standards

Various accrediting bodies and organizations set credentialing standards that outline the minimum requirements for professionals. Some widely recognized credentialing standards include:

1. The National Committee for Quality Assurance (NCQA): NCQA is a non-profit organization that evaluates and accredits various healthcare entities based on quality standards. These include health plans, physician organizations, Accountable Care Organizations (ACOs), Patient-Centered Medical Homes (PCMHs), and telehealth providers. NCQA offers credentialing programs for all these entities.
2. NCQA’s credentialing standards cover many aspects, including application content and timing, primary source verification methods, credentialing committee composition and function, recredentialing frequency and criteria, monitoring of delegated activities, and appeals processes. The organization is dedicated to ensuring that healthcare entities meet the highest performance standards. Its accreditation processes provide an objective assessment of an organization’s ability to deliver high-quality healthcare services to its patients.
3. Utilization Review Accreditation Commission (URAC): URAC is a non-profit organization that accredits healthcare entities based on their compliance with quality standards and best practices. It offers various accreditation programs tailored to different healthcare entities, such as health plans, provider organizations, pharmacies, telehealth providers, and more.
4. URAC’s accreditation programs cover multiple healthcare areas, including workers’ compensation utilization management, disease management, health call centers, health websites, wellness programs, health risk appraisal programs, chronic care management programs, and more. The commission’s credentialing standards ensure that healthcare entities meet the highest quality, performance, and compliance standards. These standards cover areas such as application content and timeliness, ensuring that healthcare entities are held accountable for meeting rigorous standards and best practices.
5. The Joint Commission: The Joint Commission is another non-profit organization that focuses on accrediting and certifying healthcare organizations and programs based on adherence to quality and safety standards. It offers various accreditation and certification programs tailored to hospitals, ambulatory care centers, nursing care centers, laboratory services, and more. These programs cover areas such as advanced disease-specific care, integrated care, patient blood management, perinatal care, primary care medical homes, and telehealth certification programs.
6. The Joint Commission’s credentialing standards are comprehensive, covering areas such as application content and timeliness, primary source verification methods, credentialing committee structure and function, recredentialing frequency and criteria, oversight of appointments, and appeals processes. These standards ensure that healthcare entities meet the highest quality and safety standards and continuously strive for excellence.

Navigating the Payor Enrollment Process

The payor enrollment process can be complex and time-consuming. To help navigate this process, we have outlined the critical steps involved:

1. Obtaining a National Provider Identifier (NPI): A National Provider Identifier (NPI) is a unique 10-digit identification number assigned to each healthcare provider by the Centers for Medicare and Medicaid Services (CMS). The NPI identifies the provider in standard transactions, such as claims and eligibility inquiries. To obtain an NPI, the provider must apply online through the National Plan and Provider Enumeration System (NPPES) or submit a paper application form.
2. Credentialing with Payors: Most payors require credentialing to ensure that the provider meets their quality and compliance standards. To begin credentialing, the provider must submit a credentialing application and supporting documents to each payor they wish to enroll with. The process can take several weeks or months, depending on the payor’s policies and procedures.
3. Submitting Enrollment Applications: Enrollment depends on successful credentialing and acceptance of the payor’s terms and conditions. To enroll with a payor, the provider must submit an enrollment application and any additional forms or documents required by the payor. The enrollment application may be submitted online, by mail, fax, or email, depending on the payor’s preference.
4. Tracking and Monitoring Enrollment Status: The provider must follow up regularly and respond promptly to any requests for additional information or clarification from the payor. The payer enrollment status can be checked online, by phone, or by email, depending on the payor’s communication methods.
5. Maintaining and Updating Information: Providers must inform the payor of any changes in their practice location, contact information, services offered, or credentialing status. It is important to renew enrollments periodically, as required by the payor’s policies and procedures. Maintaining and updating information is essential to ensure accurate and timely reimbursements.

Understanding the Connection Between Credentialing and Payor Enrollment

Credentialing is a prerequisite for all providers who want to participate in government health programs or work in accredited healthcare institutions. It also plays a vital role in payor enrollment, ensuring that providers meet health plans’ quality and safety standards. Providers cannot enroll in payor networks without credentialing and cannot receive payment for their services.

We should explore the connection between the two:

1. Government Programs: These include federal programs like Medicare, Medicaid, Veterans Administration, and Workers’ Compensation, as well as state programs like CHIP and Medi-Cal. These programs typically have fixed and standardized credentialing requirements set by government agencies and may not be negotiable.
2. National Provider Identifier (NPI): It’s also important to note that providers must obtain a National Provider Identifier (NPI) number by registering with the Centers for Medicare and Medicaid Services (CMS) through either the Provider Enrollment, Chain, and Ownership System (PECOS) or the National Plan and Provider Enumeration System (NPPES). Depending on the program, providers may also need to undergo site visits or audits by CMS or its contractors to verify their credentials and compliance with program requirements.
3. Commercial Insurance Companies: Private health insurance companies offer various plans to individuals, families, employers, and Medicare beneficiaries. Examples include Humana, Aetna, Cigna, UnitedHealthcare, Anthem, and Blue Cross Blue Shield. These companies may have varying credentialing requirements for different plans or products, such as HMOs, PPOs, EPOs, and POSs.
4. Providers must submit documents, including copies of licenses, DEA certification (if applicable), malpractice insurance, and board certification (if applicable). Providers must also submit their CVs, sign a provider agreement, and provide other supporting documents required by the payor. Providers must also complete the CAQH online application and authorize the organization to access the profile, which many payors use for credentialing and recredentialing purposes.
5. Third-Party Administrators (TPAs): These entities contract with ERISA plans or self-funded employers and are responsible for administering health plans, including claims processing and payment, utilization management, provider contracting, and other administrative functions necessary for plan operations. Examples include UMR, Meritain Health, HealthSmart, and ASR Health Benefits. These entities may have their credentialing requirements or follow the requirements of the plan sponsor or the organization they serve. Required documents are generally the same as those in the previous examples.

Challenges and Common Errors in the Credentialing and Payor Enrollment Process

1. Incomplete or Inaccurate Applications: One of the most common challenges and errors in the credentialing and payor enrollment process is submitting incomplete or incorrect applications. Providers must provide at least 15 data elements for each professional, including contact information, NPIs, and primary practice locations. It is easy to overlook some of the required information or documentation, which can result in delays, denials, or rejections of credentialing and payor enrollment applications.
2. Expired Credentials and Recredentialing: Another common challenge is allowing credentials to expire or failing to recredential. All credentials have an expiration date, requiring providers to repeat the credentialing process every 1 to 3 years. Providers may miss renewal deadlines or forget to update their information with credentialing entities or payors, which can affect their eligibility and reimbursement status.
3. Payor-Specific Requirements and Policies: Different payors may have different requirements and policies for credentialing and enrollment, creating confusion and complexity for providers. For example, some payors may require additional documents or signatures, some may have specific timelines or deadlines, and some may have different criteria or standards for different plans or products. Providers may need to keep track of multiple applications and procedures for other payors and ensure they comply with each one.
4. Coordination and Communication Issues: The credentialing and payor enrollment processes may involve multiple stakeholders, such as providers, credentialing entities, payors, state licensing boards, federal agencies, and third-party vendors. Coordination and communication among these stakeholders can be challenging and lead to delays, errors, or discrepancies in credentialing and payor enrollment information. Providers may need to follow up frequently and proactively with all parties involved and address any issues or questions that arise.

How to Avoid Credentialing and Enrollment Errors

Here are some tips to help avoid credentialing and enrollment errors:

1. Use Credentialing Software and Services: To streamline and automate credentialing and payor enrollment processes, providers can use credentialing software and services that help manage credentials, monitor expiration dates, track applications, verify information, and communicate with stakeholders. These tools can save time and effort, reduce errors and gaps, improve compliance and efficiency, and enhance provider satisfaction and patient safety.
2. Use the Council for Affordable Quality Healthcare (CAQH) Universal Provider Datasource (UPD): CAQH UPD is an online service that allows providers to submit their credentialing information to multiple payors in one place. CAQH UPD simplifies and standardizes credentialing and recredentialing processes, reduces administrative burden and costs, improves accuracy and timeliness, and protects data security and confidentiality. Providers must register with CAQH UPD, complete their online profile, and authorize payors to access their information.
3. Hire a Credentialing Specialist or Consultant: Providers can also hire a credentialing specialist or consultant to handle their credentialing and payor enrollment processes. These professionals have the expertise and experience to navigate credentialing and payor enrollment requirements and procedures, ensure the completeness and accuracy of applications and documents, follow up with payors and credentialing entities, and resolve any issues or disputes that arise.
4. Maintain Accurate and Up-to-Date Information: Finally, providers must keep their credentialing and payor enrollment information current. Providers should maintain accurate records of their credentials, renew their licenses, certifications, and insurance policies before expiration, and notify credentialing entities and payors of any changes in their practice location, contact information, or professional status. Providers should also review and update their CAQH UPD profile regularly and reattest their information every 120 days.

Credentialing with PayrHealth

In conclusion, provider credentialing and payor enrollment are essential processes that healthcare providers must complete to join health insurance organizations and receive payments for their services. These processes involve verifying and validating the provider’s qualifications, credentials, and performance and enrolling them in payor networks and contracts. Credentialing and payor enrollment are closely related and interdependent, as credentialing is a prerequisite for payor enrollment, and payor enrollment ensures payment and patient access. However, these processes can be challenging and complex, with common errors such as incomplete applications, expired credentials, payor-specific requirements, and coordination issues. To avoid these errors and ensure successful credentialing and payor enrollment, providers can use credentialing software and services, hire credentialing specialists or consultants, maintain accurate and up-to-date information, and use CAQH UPD. These tips can help providers streamline and automate their credentialing and payor enrollment processes, reduce errors and delays, improve compliance and efficiency, and enhance provider satisfaction and patient safety.

Contact PayrHealth today to learn more.

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