When discussing payer enrollment and all its components, it is important to differentiate between the meanings of each word as some are used interchangeably depending on the organization.
Payer Enrollment (Provider Process):
Payer enrollment is the process of applying to be a part of the network of an insurance company. It is important to make the distinction that payer enrollment cannot be completed until a provider has been credentialed by the payer.
Credentialing (Payer Process):
Credentialing is the process of obtaining, verifying, and assessing the qualifications of a practitioner. The process is necessary prior to a practitioner’s ability to provide patient care.
Re-credentialing (Payer Process):
This process is the revalidation of the provider’s credentials. Admin teams must maintain and ensure each provider’s data and documentation in their CAQH profile is current and attested every 120 days. If the payer is accredited or follows NCQA guidelines, recredentialing will be completed at least every 3 years. Otherwise, this can be done on a periodic basis determined by the payer. Medicare and most state Medicaid programs do this every 5 years.
Primary Source Verification:
A primary source is the original source of a specific credential that can verify the accuracy of a credential reported by an individual health care professional, which means verification is received directly from the issuing source. An example of PSV would be when an organization receives information on medical school graduation directly from the medical school, not a copy of the medical school diploma from a provider. This is completed upon initial credentialing and recredentialing.
All health facilities and payers must complete the PSV process. If the payer or organization delegates this process to a credentials verification organization (CVO), such as Andros or a provider group, they would complete this process on behalf of that payer or organization.
Privileging (Hospital Process):
Privileging is done at the hospital level, not at the payer level. Payers only ask at what hospitals the providers have admitting privileges. If the provider does not hold admitting privileges, the payers need to have an understanding of how that provider will admit patients who need hospital care (admitting arrangement). This is to ensure the payers members have access to the care they need by in-network hospitals and providers.
Provider directories are an important tool that payer members use to select and contact physicians and other contracted healthcare providers who deliver medical care. Beneficiaries and their caregivers rely on accurate provider directories to make informed decisions regarding their health care choices.
Provider Data Management (Provider and Payer Process):
Provider data management (PDM) refers to the monitoring and tracking of provider directories, demographics, state licenses and renewals, board certification, malpractice insurance policies, work history, education and accreditations, and participation in networks, all within a centralized management platform.
As one can see, the payer enrollment and credentialing process entails several components that must be differentiated before reviewing how the process can be improved.
Next week we’ll review how payer enrollment affects revenue cycle management, and how automating this process can save hundreds of thousands of dollars.