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

Reimbursement News

Using Payer Enrollment to Jumpstart Revenue Cycle Optimization

Outsourcing payer enrollment services helps healthcare organizations streamline the enrollment process, navigate payer rules, and monitor revalidation.

Revenue Cycle Management

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- Payer enrollment services help healthcare organizations to unravel the complex process of credentialing providers and enrolling them in payer networks.

Payer enrollment is the process of a provider joining a health insurance plan’s network. The process includes requesting participation in a payer network, completing credentialing requirements, submitting documents to the payer, and signing a contract.

Healthcare organizations must ensure payer enrollment is complete for each of their providers in order to get paid for delivering care. Payers will not reimburse healthcare organizations for services rendered by a provider who is not officially part of a plan’s network.

Failing to complete the payer enrollment process in a timely manner will also lead to an uptick in on-hold claims — and in some cases claim denials.

But completing payer enrollment is an oftentimes long and complex process for most healthcare organizations and the need to streamline and improve the process is increasing as providers face an increasingly competitive marketplace.

The Association of American Medical Colleges (AAMC) recently projected the physician shortage to increase, growing to up to 120,000 doctors by 2030. Other provider types are also in low supply, with the Bureau of Labor Statics estimating 1.09 million job openings for nurses by 2024.

With fewer providers available, attracting and retaining high-quality care delivery staff has proved a major challenge for healthcare organizations. The turnover rate among healthcare reached 19.2 percent in 2015, with voluntary turnover rates seeing significant growth, according to data from Compdata Surveys.

As healthcare organizations find their provider workforce frequently changing, medical service staff are finding their systems difficult to keep current. As a consequence, the organization’s bottom line may suffer as more claims are placed on hold.

For busy medical services staff or patient financial experts, outsourcing payer enrollment services to a third-party can help. Payer enrollment services allow organizations to streamline the process, manage the wide range of payer requirements and processes, and stay abreast of expiring enrollments and credentials.

Streamlining payer enrollment to save time, money

Payer enrollment is a complex process oftentimes taking several months to complete, explained Tracy Watrous, Vice President Member Services and Content Development at MGMA.

“Payer contracting, whether it is commercial payers or government payers, and the credentialing process is complicated, cumbersome, lengthy and time-consuming,” said the former medical group director. “It’s very hard for a medical practice to keep up without getting discouraged by the process because it is lengthy and complicated.”

Payers typically require between 90 to 120 days to complete provider credentialing alone, causing the entire enrollment process to span months on average.

Smaller plans with limited resources may take even longer to process provider enrollment.

Healthcare organizations can make matters worse by failing to collect all the necessary documents for credentialing and engaging in duplicative efforts to complete payer enrollment. As a result, organizations are likely to face delays in claims reimbursement (and possibly an increase in denials) when workflow inefficiencies add time to an already lengthy process.

Outsourcing payer enrollment to a third party can help healthcare organizations streamline provider credentialing and health plan participation. Through payer enrollment services, these external resources assist with gathering the necessary documents for credentialing and enrollment and tracking payer responses to provider participation requests.

A streamlined payer enrollment process means that providers can start seeing patients and billing for services sooner.

Navigating payer rules and requirements

Healthcare organizations work with dozens of payers at once, and their providers must be enrolled with each insurance company for timely reimbursement.

However, private and public payers do not have a standardized process for payer enrollment. Medical services staff must understand each payer’s rules and requirements when it comes to a plan’s enrollment.

For example, Humana requires providers to use a service from the Council for Affordable Quality Care (CAQH), called CAQH Proview, to submit credentialing information. Providers also need to have a Drug Enforcement Agency and/or Controlled Dangerous Substances certificate.

Similarly, Aetna requires providers to use the CAQH Proview platform. But the payer also uses quality standards set by the National Committee for Quality Assurance (NCQA) to evaluate provider credentials.

Navigating the web of unique payer enrollment rules and forms can bog down the entire process at a healthcare organization, causing a boost in on-hold claims.

Employing a third party for payer enrollment services can help healthcare organizations maneuver payer rules and requirements. Payer enrollment services vendors should work with each payer a healthcare organization contracts with to understand each payer’s unique rules, forms, and processes for adding a provider to a health plan’s network.

Staying on top of reenrollment

Despite getting each provider in a healthcare organization enrolled in the right payer networks, the payer enrollment process is not complete. In fact, payer enrollment is an ongoing process for each provider.

Payers require providers in their networks to re-enroll or verify their credentials every couple of years to ensure network providers are still eligible to deliver high-quality care. For example, the Affordable Care Act mandated Medicare provider revalidation every five years.

Healthcare organizations will find their claims put on hold and billing rights revoked if providers are not re-enrolled or validated by a specific deadline.

Organizations will also face claim delays and denials if they do not frequently update provider data and monitor certificate or documentation expirations.

Tracking when enrollment and certificates expire for each provider is time-consuming and error-prone. But an outsourced payer enrollment service specifically monitors enrollment and documentation expirations.

A payer enrollment service also regularly updates provider data on required platforms, such as CAQH’s Proview.

At its core, outsourcing payer enrollment services opens communication between healthcare organizations, payers, and providers. Outsourcing the process facilitates communication between the three stakeholders to ensure enrollment is approved and stays approved.

With a more open payer enrollment process, healthcare organizations should see more of their claims paid on time and without complication.

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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