Provider Enrollment | 10.21.24
What Is Provider Enrollment?
By Nicole Pittman
When I’m asked about the work that I do and I respond with “provider enrollment”, I’m met with a lot of blank stares.
“What exactly is that?”
I’m glad you asked — allow me to explain!
If you have health insurance coverage and you go to the doctor or hospital to get scheduled for a procedure, someone in the office will call the insurance company to verify your provider is currently in network with your plan.
“In network?”
Yes. When you sign up for health insurance, you’re usually given a manual or directed to their website to see which providers, hospitals, and offices have signed an agreement/contract with the payor for a discounted rate, which means you’ll pay lower costs out of pocket for your portion of coverage toward your deductible. If the provider or facility is out of network, your out-of-pocket costs are higher.
“So which part do you do?”
I do the leg work — when the provider joins our practice or we open a new office, my job is to ensure the provider is in network and contracted with the insurance plans that my practice accepts. I also ensure our new office location is participating with the insurance payors as well.
When I am notified of a new provider who has cleared our credentialing and privileging committee (CPC), I will prepare a packet of all the insurance applications they will need for whichever office(s) they will be seeing patients in based on county, as well as hospitals they will be rounding in, as some hospitals have a private insurance network for their providers. For a new location, the same applications are completed, only from a facility demographic standpoint including types of specialties treated, in-office procedures, labs, and PET/CT scans. A list of providers who will be joining that office is also submitted, so the providers will just have that location added to their billing profile.
The applications are prepped and sent to the providers and then, once returned, audited for accuracy, then sent to the applicable insurance payors with any extra requested documentation, such as a medical license, educational diplomas, and certificate of insurance.
I’ll follow up with the payors on a regular basis until all the providers’ billing numbers/par status with the plans are obtained, and the information is loaded to our internal database. This database is where the provider’s office(s) will be able to see which plans the provider is currently participating with or if any are still pending completion at the payor, which will determine whether the patient can be seen now or if they will need to wait until their provider is completed. Because of the urgency of the oncology-related specialties we treat, if a patient cannot be seen in a timely manner, we’ll suggest finding another provider in the same participating practice to see the patient instead.
I’ve been in the provider enrollment and credentialing field for over 20 years in different arenas such as a nationwide physician staffing company, a well-known revenue cycle company, and a large private practice. I’ve handled enrollments in almost every contiguous U.S. state and worked with many different specialties. I continue to learn new things every day, and it just fascinates me.
Even though I’m not a medical practitioner, what I do is crucial to patient care. The last thing we want the patient to worry about is whether or not they can see the provider they want or need and if they will have the proper coverage.
Not all heroes wear capes or scrubs — sometimes we wield applications and rosters!