By Gregg Opper, PatientClick Staff
Three steps a provider needs to do to earn the most from payers. Get credentialed (can take up to 160 days), then work out a contract with the payer (typically 90 to 180 days), and then through a clearinghouse get enrolled with payer to send claims electronically and receive payments electronically too. Then a fourth step would be to make sure your patients have insurance from a payer that you have completed the previous steps.
Credentialing is where a payer sends a provider requests for information on their credentials (for practicing and being a provider), and then checks out that information. The process can take up to about 160 days to complete for each payer. There is normally a lot of paperwork, but some clearinghouses assist with the paperwork and submittals. After a provider is credentialed, they can proceed to the next step with the payer, getting a contract.
Contracts with payers set how much a provider will be paid by a payer and the time period that it will be valid. Providers need to be aware of when contracts start and when they terminate. They need to know when a contract terminates so they can renew or negotiate new contracts, and so they don't treat patients, expecting to get paid under the contract and then find they no longer have a contract. Once a provider has a contract with a provider they can proceed to enrollment.
Enrollment is where a provider enrolls through a clearinghouse to send claims and receive payments electronically. It is a lot faster than snail mail.
Warning: This whole process can be confusing, stressful, and frustrating ... but it is important that the provider or a designated person stay on top of the process.
If you have all three steps completed for each payer, then you should be setup to receive the optimum payments from your payers.