Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid


States Look to Streamline Payer Enrollment, Cut Provider Paperwork

Arizona and Texas have implemented new rules to make it easier and faster for healthcare organizations to complete the complex payer enrollment process.

Payer Enrollment

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- Healthcare is a waiting game, with the most common example being the patient waiting room. But patients aren’t the only healthcare stakeholders left waiting. Healthcare organizations oftentimes wait months to receive payer enrollment approvals from health plans.

From provider credentialing to health plan contracting, payer enrollment takes an average of 90 to 120 days to complete. And for some health plans, payer enrollment make take even longer. For example, healthcare organizations may be waiting up to 180 days for Medicare to verify a provider’s credentials and approve their participation in the federal healthcare program.

Waiting months to receive a health plan’s stamp of approval may be hurting care access, especially in light of the recent physician shortage. The Association of American Medical Colleges (AAMC) projects the healthcare industry to face a shortage of up to 120,000 physicians by 2030.

With payer enrollment impacting care access and the bottom lines of healthcare organizations, a handful of states are looking to accelerate the process to ensure their residents can quickly receive care from qualified providers.

States take the lead with reducing payer enrollment time

Arizona is the most recent state to pass a payer enrollment law. Governor Doug Ducey signed an unanimously-passed bill HB2322 into law in April 2018.

By Dec. 31, 2018, the new law will require health plans to verify provider credentials and load the provider’s contract information into their billing systems within 100 days after the payer receives a complete payer enrollment application.

The law also ensures healthcare organizations receive notice of incomplete payer enrollment applications in a timely manner. Health plans must notify healthcare organizations within seven days of receiving the application if the application is deemed incomplete by their standards. The notification must include a detailed list of all the items needed to complete the application.

Payer enrollment is a significant challenge for providers in Arizona. Several hospitals in the state reported that some payers took 90 days or longer to complete the approval process in more than 40 percent of applications, according to the Arizona Hospital and Healthcare Association (AzHHA).

Some hospitals even had to wait eight months or more to receive provider credentialing approvals from payers in the state, the hospital group reported.

Arizona policymakers intend for the law to tackle payer enrollment waits, as well as bring the revenue cycle management process into the digital age. The law will mandate health plans to communicate application receipts and notifications of incomplete applications electronically.

Despite the industry-wide push to automate revenue cycle management processes, payer enrollment and disenrollment still relies on manual processes. One large, national health plan recently reported to Council for Affordable Quality Healthcare, Inc. (CAQH) that just one-half of its enrollment and disenrollment applications were fully electronic.

Electronic payer enrollment can streamline provider applications and claims reimbursement, resulting in patients accessing high-quality providers sooner.

 “Arizonans’ access to care is compromised when it takes an excessive amount of time to credential physicians,” stated Arizona Medical Association Executive Vice President Libby McDannell. “This legislation ensures doctors are putting patients, not paperwork, first.”

Texas is another state that has implemented regulations to speed up the payer enrollment process. In 2010, the Lone Star State implemented a rule in their insurance code that allows physicians joining an established medical group to be paid as if they were already participating in the medical group’s plan.

During the payer enrollment application process, physicians can still practice medicine and receive reimbursement if a they are licensed in Texas, remain in good standing with the Texas Medical Board, have submitted all credentialing documentation to the health plan, and agreed to the contract terms between the medical group and the health plan.

The Texas Association of Health Plans and the Texas Medical Association are also taking payer enrollment to the next level within their state. In April 2018, the groups launched a credential verification organization for all Medicaid plans in the state.

The organization will take over primary source verification for all newly credentialing and recredentialing Medicaid providers.

As more states take action to streamline payer enrollment, policymakers across the country are proposing similar bills to reduce the amount of time providers are waiting on payer enrollment approvals. Louisiana lawmakers proposed a bill in April 2018 that would streamline credentialing across industries, including healthcare, to attract and retain business in the state.

Pennsylvania policymakers also laid a healthcare-specific credentialing bill on the table in 2017. The bill would require payers to accept CAQH credentialing applications and issue a provider credentialing determination within 45 days after receiving a complete CAQH application.

What state-level trends mean for healthcare organizations

Healthcare organizations in Arizona and Texas should see their payer enrollment applications come back faster and their time to reimbursement decline.

But state-level actions to accelerate and streamline the payer enrollment process could also improve the payer enrollment process for healthcare organizations across the country. Arizona’s new law and the Texas Medicaid credentialing verification organization can serve as examples for other states looking to reduce the burden of payer enrollment.

The state-level trends may also bolster the industry-wide push to improve payer enrollment. CAQH is developing standards and rules for electronic communications between payers and providers. The committee aims to streamline communications like payer enrollment disenrollment.

In the meantime, healthcare organizations across the country can ensure their new providers are ready to deliver care and get paid for it by being proactive with payer enrollment. Payer enrollment experts advise healthcare organizations to start the process at least 90 days before a new hire’s start date.

Healthcare organizations should also consider going paperless. Medical staff traditionally rely on manual processes and data collection to complete payer enrollment applications.

However, automated systems built in-house or acquired through third-party services can significantly reduce the burden, paperwork, and time needed to complete payer enrollment. Healthcare organizations should create an electronic database of provider information to manage and track payer enrollment applications.

Developing a proactive payer enrollment strategy will ensure healthcare organizations receive reimbursement for care delivered by qualified providers as healthcare leaders at the state and federal level tackle the challenges associated with payer enrollment.

The timely enrollment of providers into health plans has become a crucial requirement of sustaining a thriving practice. symplr’s payor enrollment services can help you reduce the paperwork burden, streamline your provider onboarding process and enhance the profitability of your healthcare organization. We make payor enrollment simpler for healthcare organizations nationwide. For more information, email [email protected] or visit us at 


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