Credentialing and Enrollment: Diligence & Expertise Wins the Day

For more than 25 years working with health centers to optimize reimbursement, persistent adherence to a diligent process trumps the most seasoned staff or the most dazzling software. Simply stated, there is nothing sexy about getting claims paid or providers enrolled and credentialed. Health center billing, credentialing and enrollment professionals simply must do the work. Every. Damn. Day. 

Whether a health center CFO, CEO, medical director or billing lead, knowing only a smattering about provider enrollment and credentialing, here is a short list of things to remember.

1.       Payers lose applications. Everyone loses things…  money, keys, wallets, kids, etc. It happens and, most of the time items, resurface. However, payers are not going to exert the same energy a health center would to assure submitted applications are complete and ready for committee. That is the responsibility of a health center’s credentialing and enrollment expert/advocate.

2.       Payers have little incentive to expand the base of providers seeking payments. Think about it: more providers results in more people seeking more payments. If payers make money by retaining collected premiums, what exactly is the payer’s motivation to expand the network or those seeking expanded dollars? If an answer surfaces, please let the rest of us know. Only fully complete and accurate applications are accepted and pass scrutiny. A health center enrollment and credentialing professional needs to make certain all applications are prepped for successful review by a payer’s committee.

3.       ANY missing (or expired item) is reason for a denial. Ever pull out a government ID at TSA or have a credit card declined because the expiration date is passed or too imminent? Especially during the COVID PHE, shifting leniencies make it difficult to stay on top of expiring certifications, licenses, autopayment accounts, etc. Payers… all payers… start every submission with an attempt to deny. One need only understand what a subrogation department does; i.e., evaluate as many claims as possible to see if another payer might be primary or singularly accountable for payment. These are not nefarious activities but part of a payers diligent efforts to be profitable. 

This list could expand but three short items afford health center leadership a targeted conversation with the credentialing and enrollment professional. A health center credentialing and enrollment professional must utilize experiential savvy, credentialing/enrollment software, daily checklists, and dogged follow up with ALL payers to assure rapid enrollment and credentialing of providers.  Unfortunately, for credentialing and enrollment, most health centers utilize a “volun-told” (vs. volunteer) approach for assigning responsibility for credentialing and enrollment. No real expert. No real process. No ability to be diligent. 

Be honest about the potential for success… and the downside of losing thousands of dollars… for unsuccessful credentialing and enrollment. While any credentialing and enrollment company would love a new customer, health centers can successfully do this work themselves. Critical to remember is that successful credentialing and enrollment by health centers does require investment in at least one real professional or an ongoing relationship with a credentialing and enrollment consultant. Either way, don’t allow a process that can be controlled and highly successful be marred by inexperience, lack of process/diligence. Make the right investment, internally or externally, to optimize credentialing and enrollment success.

Since 1998, PMG has worked with hundreds of health centers in all fifty states and territories. Contact us today to see how we can help streamline your credentialing and enrollment process.