Provider/Payer Enrollment Tips and Tricks
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1 Provider/Payer Enrollment Tips and Tricks Thea Hensley Provider Enrollment Coordinator Cody Regional Health
2 Vocabulary Provider/Payer Enrollment-Refers to the gathering and submitting of information to payers in order to join their networks. Network-The group of facilities and providers an insurance companies has approved for enrollment. Networks allow patients to utilize maximum benefits for services rendered. Smaller out of pocket costs for the patient. Credentialing- 1. Used by Medical Staff Services to describe what they do when onboarding a provider. Making sure the provider is qualified to practice. 2. Used by insurance companies in the onboarding of providers to their networks. Provider/Payer Enrollment is NOT credentialing. The insurance companies may credential for their purposes but the Provider/Payer Enrollment process is not credentialing.
3 What is the purpose and why is it important? To be able to provide services for patients at the best rate for the patient. In some cases including Medicare, to get the facility paid. Some insurance contracts state we can t bill a patient if our provider is out of network for the patients plan.
4 Where does Provider/Payer Enrollment belong? Medical Staff Services Allows for information sharing without breaking the rules. Allows providers to find everyone they need all in one place in case of questions. Patient Financial Services Allows for accurate billing processes, especially for obscure insurance companies. Ability to communicate with the CFO regarding insurance contracts. Allows communication and the ability to train with registration staff.
5 Where to start. Make a list of your most billed insurance companies. See slide 12 for my list. Contact all of the insurance companies Provider Enrollment/Credentialing departments and get a current roster. Use those rosters to compare to your current provider list and build a spreadsheet. Physician Name Medicare Medicaid BCBS Cigna FC Midwest Dr.A 6/1/ /15/2015 x 7/1/2012 x Dr.B 4/1/2016 9/1/2015 9/4/2015 9/1/2016 Dr.C 11/1/2013 2/11/ /1/2013 3/21/2014 x Dr. D 12/4/ /19/2017 2/6/2018 x Dr. E 4/1/2015 4/1/2015 4/1/2015 4/24/2015 x Dr. F 2/5/ /8/2013 8/12/2013 x Fill in holes by using the insurance companies websites to check the providers participation.
6 The Top Two Wyoming Medicaid and Medicare
7 Wyoming Medicaid If a provider is listed on this spreadsheet they are active with WY Medicaid.
8 *Every provider listed on a WY Medicaid claim has to be an enrolled provider or the claim will not be paid. This includes providers referring for labs and radiology.
9 Linking a WY Medicaid Provider to an Enrolled Group. If it is an initial enrollment, add the linking information in the Additional Information section on the application. Example wording: Please link Dr. A, NPI to The Group XYZ, NPI effective 05/01/2018. If it is for linking an existing WY Medicaid provider, fax a letter on letterhead, with the linking information to Conduent You can also them the information at wycustomersvc@conduent.com. This can also be used to send updated license information. Updates take about 2 business days to complete.
10 MEDICARE
11 Medicare Paper vs. PECOS Paper Pros Paper Cons PECOS Pros PECOS Cons Straight forward if you know the fields. Hand to the provider for signature. Scanned or copied record of submission. Confusing 30pg application with little instruction. The amount of paper. Electronic Application guided by questions answered. Provider has to know login info and give surrogacy Provider has to electronically sign in timely manner.
12 Medicare Forms 855I and 855R CMS-855I All providers enrolling with Medicare in their area for the first time. Noridian is the MAC for WY. If the provider is currently enrolled in AK, AZ, ID, MT, ND, OR, SD, UT, WA or WY, this form is not necessary. All providers need completed sections 1,2,3,4b,13 and 15 PA-C s cannot reassign benefits so they do not complete section 4 Nurse Practitioners must answer section 2 section K regarding SNF services. A copy of the Nurse Practitioners diploma must accompany the application. CMS-855R Must accompany the CMS-855I for all providers except PA-C s. If the provider is already enrolled with the MAC this is the only form needed. Must be signed by the provider and a Delegated or Authorized Official from the group.
13 Commercial Payers
14 Must Have Information, for a Complete Provider/Payer Enrollment. Name, DOB, SSN, NPI Education, Internships, Residencies, Fellowships including Month and Year of start and completion. Licenses: State License, DEA (Must reflect WY address), CDS Board Certifications CV Medical Malpractice Insurance information Three professional references. Include Name, Specialty and Phone Number. CAN T use Peer References. Information on any Medical Malpractice claims in the last 10 years. Must get from provider, can t use information used for credentialing.
15 CAQH for Commercial Payer Enrollment CAQH (Council for Affordable Quality Healthcare, Inc.) is essentially a credentialing database. Cigna and United Healthcare require providers to have an up to date CAQH profile before they will accept for enrollment. Start to Finish a profile takes 1-5 hours to finish depending on providers history. Needs re-attestation every 120 days Even after a profile is built you have to contact the insurance companies to initiate their credentialing process.
16 New Provider Process Make sure I have everything I need (see slide 14) I do start applications without references and malpractice claim information. I just can t submit until I get it. Check Insurance websites for provider participation to determine if I need a whole application or just add them to the group. (insurance specific) Check CAQH to see if they have a profile. NO? -Start to build one Yes!- Find out if the provider has their login info or if it is with their previous group. Have the provider look over and sign the completed applications. Send applications and supporting documentation, via certified mail, fax or to the insurance companies. (insurance specific) WAIT- Some companies have a quick turn around, I have seen some take over 200 days. Keep an eye on your and snail mail for approval letters and dates. Watch your mail for re-enrollment/re-credentialing requests every 3-5 years depending on the company.
17 Training and Information Resources Decision Health- National Provider Enrollment Conference CMS.GOV UHC News Bulletin
18 Q&A
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