Frequently Asked Questions
Starting a new practice, adding a new provider, changing and/or adding practice locations, or breaking away from a group to become solo, all require enrolling with insurance companies in order to become a participating provider with that payer. Provider Enrollment is the process of requesting participation in a health insurance network as a provider rendering services. The process involves requesting participation, completing the credentialing process, submitting supporting documents and signing the contract. Enrollment is also the validation of a provider in a public health plan and the approval to bill the insurance company for services rendered.
Primary Source Verification is the process of verifying the original source, or institution, of a specific credential, including but not limited to, licensure, education, and training, in an effort to determine, and verify, that the credential is valid. In addition, primary source verification
Different types of healthcare facilities are required by law and regulatory guidelines to conduct primary source verification of all providers who they are considering the allowance of privileges within the facility. Facilities and health plans consider credentialing the process of verifying and validating that a healthcare provider is qualified and competent to provide quality care within the scope of the provider’s licensure. This includes adhering to the state and local laws, complying with the rules and regulations of the accrediting bodies and following organizational bylaws, policies and procedures.
Primary Source Verification can be a very tricky and time-consuming process. If conducted incorrectly, it may place the client in danger, and could have some very serious repercussions for the licensure of the organization.
The decision whether to become an in-network provider for local payers is an important one for any provider. And like anything else, organizations must consider the pros and cons of obtaining and maintaining in-network provider status.
One important benefit to becoming a participating provider with an insurance company is an increase in referrals, and in essence, your revenue. As an in-network provider, the organization becomes listed in the payer’s provider directory, that which potentially generates an entirely new client base.
Individuals who have insurance coverage, more often than not, will seek an in-network provider in order to maintain lower out of pocket expenses. In addition, the insurance company itself, will direct patients to your practice via any individuals who call their insurance carrier for recommendations. Thus, a benefit for becoming a participating provider is the opportunity to obtain new patients for your practice.
Once the contract is generated, the rates are negotiable. You are not tied to the rates that they offer off the bat! Once, the rate is agreeable to the provider and if the rate offer makes sense for your organization, there is also the benefit of predictability of reimbursement. This makes for much easier financial planning and budgeting. Once an organization makes the final decision and agrees to the terms of the contract offered, and the offer is accepted, being in-network may simplify the complex claims process because billing would be governed by the terms of one mutually agreed-upon contract.
Completing enrollment, and re-enrollment applications for insurance companies, hospital staff privileges, and the paperwork list goes on, can be extremely time consuming and tedious. Application processing, tracking and diligent follow-up is difficult to manage, and many providers don’t realize that a successful provider enrollment process needs to be just as important as any other aspect of running a successful practice. By reducing provider enrollment timeframes, practices can generate incremental revenue. Using a third-party that specializes in enrollment, such as Emerge and See, can speed up the process by ensuring accuracy and efficiency of each application submittal, while costing far less than hiring someone internally to perform these functions.