What Is Provider Enrollment?

To continue providing the best patient care services, your healthcare facility needs to generate revenue. And to generate revenue, you need to have a list of patients who view your facility and care services as “in-network.”

For this, there’s provider enrollment.

This quick guide will take a closer look at the significance of provider enrollment, how it relates to credentialing, and how to streamline the process for the benefit of your practice.

Provider Enrollment Definition

In the most basic terms, provider enrollment (sometimes referred to as payer enrollment) is the process through which healthcare providers apply to be included in a health insurance network.

As an in-network provider, you will be able to treat patients who carry that insurance and be reimbursed for your services. People who carry that insurance are also more likely to seek out your practice if you are listed on the insurance company’s website as a preferred provider. Because of this, the financial impacts of provider enrollment are numerous. Being included as a preferred provider in a health insurance network is also known as joining an insurance panel.    

How Provider Enrollment Works

The provider enrollment process can be broken down into three phases: provider enrollment application, provider credentialing, and negotiation. Below is a more detailed description of each of them.

• Phase 1: Application – Provider enrollment starts with identifying which insurance companies, or payers, you want to partner with. It’s important to understand which health insurance plans are most popular among the people in your community so that you can make an informed decision that most benefits your practice. That doesn’t always mean choosing the largest network either. Because the process can take months, you should be certain that your provider application is justified.  
• Phase 2: Credentialing – If the insurance company wants to move forward with your application, they will need to verify your competence, license and qualifications as a healthcare provider. This verification process is commonly referred to as provider credentialing. You will need to provide a significant amount of enrollment information including documentation, including diplomas, certifications, work records, affiliations, tax information, proof of insurance, immunizations, and much more. Proper preparation during this phase can save you weeks, if not months, on the entire process.
• Phase 3: Negotiation – Once the insurance company verifies that you are competent and qualified to provide patient care services, they will offer you a credentialing contract. This contract will officially make you one of their in-network providers. The contract will have many terms and clauses which dictate your partnership. Most notable are terms defining your reimbursement rates. You may want to negotiate better rates in your enrollment forms before signing.

What Is Provider Enrollment Going To Do for Your Practice?  

Successful provider enrollment helps you attract new patients, generate more revenue, and expand your practice or health care program. By the same token, failure to perform the provider enrollment process successfully can cause massive financial losses, stall business, limit your ability to deliver the best patient care services to as many people as possible, and damage the reputation of your practice.

For these reasons, provider enrollment—while a complex and time-consuming process—should be in the forefront of your priorities.  

Provider enrollment, credentialing, and contract negotiation make up a very lengthy process. Credentialing alone often takes the insurance company up to 90 days, while the contract negotiation and finalization process can tack on another 30 to 45 days.¹ These figures represent the length of the process when it moves along at an average pace—it can take significantly longer if you make any errors along the way.

Some common mistakes include:

• Not answering every question on the application in full detail
• Using incorrect formats on application pages for things like phone numbers and dates
• Failing to provide all of the requested documents
• Providing incomplete documentation (for example, sending 2 references instead of 3)
• Using secondary source material instead of primary documents (for example, an unofficial medical school transcript)  

Doing any of the above can cause major delays, or even prevent you from joining the insurance panel. It’s important to keep in mind that the average healthcare provider works with not just one, but 25 payers.² That means a lot of paperwork to keep track of and many opportunities for small but significant errors.

Therefore, you can think of proper provider enrollment not only as something that adds value to your practice, but as a vital process that can prevent disaster.  

The Benefit of Provider Enrollment for Administrators

Providers themselves are not the only people who need to take the provider enrollment process seriously. Healthcare facility administrators—whether they work for a small family practice or a large hospital in a metropolitan city—should also understand the benefits of efficient provider enrollment, as well as the possible consequences of failing to enroll properly.

The effects of provider enrollment can be felt across the entire organization.

Consider, for example, that you work as an administrator at a local clinic that staffs five physicians. The business model of your clinic is such that these five physicians are compensated for their services by the business through salary and benefits. Later, the costs of services are supposed to be reimbursed by patients’ insurance companies. This is how the clinic generates revenue.  

However, if these five physicians fail to submit their provider enrollment applications on time, or make common mistakes during the credentialing process, or face delays in the negotiation phase—your clinic could face substantial losses. During the time that the five physicians worked and were not yet credentialed and contracted as in-network providers, your clinic would receive zero reimbursement for the patient care services rendered. To avoid this, administrators can:

• Stop viewing provider enrollment as a back office or behind the scenes task
• Take a more active role in assisting providers with their applications  
• Reduce the time it takes to enroll providers by integrating with CAQH

What is CAQH?

The Council for Affordable Quality Health Care, or CAQH, is a nonprofit organization that presents a simpler solution to one aspect of the provider enrollment process.  

In the past, every insurance company had a unique provider enrollment process, meaning application forms and credentialing requirements varied from payer to payer. This caused lots of headaches and wasted time for providers, who were forced to tailor their applications for each specific payer. (And remember: the average provider works with 25 payers!)  

In response to this problem, CAQH developed a universal application through which providers could upload all of their personal information and supporting documents. Then, any insurance companies could access this online application when they wanted to verify a provider’s credentials and add them to their insurance panel.

The list of participating insurance companies who now use the CAQH application for provider enrollment includes:  

• Aetna  
• Anthem  
• Blue Cross BlueShield
• Cigna
• Empire
• Humana
• Kaiser Permanente
• Liberty
• MetLife
• Simply Healthcare
• Unicare
• United
• WPS Health Solutions

Provider Enrollment for Medicare

The provider enrollment process is different if you want to be able to accept Medicare.

Along with Medicaid, Tricare, and other governmental health programs, Medicare has its own standard forms that must be filled out and sent to the government representatives in your community.

When trying to enroll as a provider with Medicare, it’s best to seek the support of someone who is specifically familiar with the Medicare provider enrollment regulations. Here are a few key items to keep in mind if you’re thinking about enrolling with Medicare:

• You need to have a primary location where you deliver patient care services
• You must include banking information in your application so that you can receive EFT payments, which is how Medicare reimburses providers  
• Your application must include the personal information of every individual who has an ownership stake in your practice or facility
• If you were born outside of the United States, you will need to provide citizenship documents with your application  

How To Make the Provider Enrollment Process Easier

Whether you want to enroll with private insurance or government health plans like Medicare, it helps to have the support of professional strategists. You don’t want to end up missing reimbursement payments and facing severe financial losses.

Healthcents is the number one solution to healthcare contracting management. You can rely on state of the art techniques, tools, and data to ensure you’re signing the best contracts with the right payers.

Healthcents coordinates with payers so that you can focus on delivering the best care to your patients. Provider enrollment doesn’t have to be such a painstaking process. With Healthcents, applications are quick and easy, and negotiations are handled by a team of experts so that you get the very best reimbursement rates.

If you want to start earning more and worrying less, contact us today.

Sources: ‍

1. National Credentialing. What is Provider Enrollment. https://nationalcredentialing.com/what-is-provider-enrollment/#:~:text=Provider%20Enrollment%20(or%20Payor%20Enrollment,inclusion%20in%20their%20provider%20panels.&text=Most%20commercial%20insurance%20networks%20have,separate%20from%20the%20credentialing%20step.
2. VerityStream. 4 Tips for Accelerating Provider Enrollment. https://www.veritystream.com/resources/details/blog/2018/12/19/4-tips-for-accelerating-provider-enrollment  
3. MedConverge. Difference Between Provider Credentialing and Provider Enrollment. https://medconverge.com/difference-between-provider-credentialing-and-provider-enrollment/  
4. CAQH. Membership/Participant list. https://www.caqh.org/solutions/caqh-provider-data-list-participating-organizations

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