You acquired a new 10-physician practice on January 1st. All 10 immediately began seeing patients on your behalf, and your hospital began paying these physicians their agreed-upon salaries and benefits. It is now April, and none of the physicians has yet completed the full provider enrollment process. The physicians have collectively generated almost $4 million in charges for which your hospital will never be reimbursed by payers, and you are facing a stunning write-off for the first half of the year.
Has a version of this scenario played out in your organization? If so, you are not alone.
For years, hospitals have considered provider enrollment a back-office function. It is separate from the provider credentialing process but shares many of the same characteristics - it is complicated, redundant, and time-consuming. The enrollment process may cause frustration to providers and administrative staff alike, but it is not traditionally considered a strategic function worthy of attention or added resources. However, a series of new industry developments has greatly escalated the importance of the enrollment process. Unfortunately, many healthcare leaders are only realizing this as they incur significant and surprising revenue losses, and the result is that hospital leaders are now scrambling for better solutions to this new administrative nightmare.
Our research shows that a high percentage of those who manage the provider enrollment function are struggling with the effectiveness and efficiency of their current process. Their top priority in this area is to reduce the time it takes to enroll providers. Download our infographic - The Inefficiency of Manual Provider Enrollment Application Processes, and we will walk you through 4 ways your organization can accelerate your provider enrollment process.
One way to speed up the process during the initial provider enrollment is to make sure that your enrollment applications can be automated with pre-formatted payer forms. Every payer has their own unique set of data required to enroll a provider. The more of this information that can be pre-populated when filling out the initial application the quicker the application can be submitted. An added bonus would be to have your enrollment process integrated with your credentialing process so that all of your individual provider information can also be uploaded to the enrollment application forms.
What is PECOS? PECOS (Provider Enrollment, Chain and Ownership System) is an electronic portal sponsored by the Center for Medicare and Medicaid Services that supports the Medicare Provider and Supplier enrollment process by allowing registered users to securely and electronically submit and manage Medicare enrollment information. The PECOS submission can be automated with software functionally that allows for direct data exchange between your system and the PECOS electronic portal. A direct exchange will ensure data accuracy and faster billing.
What is CAQH? CAQH (Council for Affordable Quality Health Care) is a non-profit alliance of health plans and trade associations, developing and leading initiatives that positively impact the business of They host a universal credentialing database for health care providers.
How does it work? A provider requests participation in a network that accepts the CAQH application. The health plan initiates an online account for the provider. The online application is completed and submitted to CAQH along with several other supporting documents. Once the application is complete, any insurance company that accepts the CAQH application can access the provider’s information, expediting the enrollment process. The provider information typically needs to be updated every 120 days.
Many health insurance plans today are signing on with CAQH. Having the ability to directly integrate with their database to submit and update provider data allows you access to multiple plans at once, submit ONE application, saving you time and significantly increasing the efficiency of your enrollment process.
The average healthcare provider works with 25 payers. That means a lot of paperwork just to get paid. As we discussed earlier, each payer requires a unique set of forms, procedures, and data to be submitted in order to enroll for Electronic Funds Transfer (EFT), Electronic Remittance Advice (ERA), Electronic Data Interchange for Claims (EDI) and other common provider-payer transactions. When providers make minor changes to their enrollment information, they must submit these forms again.
Traditionally, time is wasted dealing with paper forms, correcting manual errors, and tracking down the status of enrollments. By streamlining your process with an automated payer transaction system, providers can fill out a simple online form once and the enrollment data is delivered to all payers from an online list with a single click. The result? Less paperwork, faster payment.