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What is Provider Enrollment exactly?

Provider Enrollment is the process healthcare providers go through to “register” as an approved medical service provider or entity with insurance companies. Doctors, nurses, hospitals, labs, and other medical facilities must complete enrollment paperwork before they can be included in a network.

Enrolling to become an “in-network provider” allows medical practices to become accessible to a pool of insured patients. As a result, health plans only cover in-network providers at the best rates for its respective members, so doctors must enroll if they want the insured business and respective reimbursement.

Why does this cumbersome and long process exist?

In a nutshell, it is required due to complex and necessary regulations. Government rules require diligent vetting to combat fraud and abuse. While frustrating, such oversight provides a mechanism to filter out bad actors or non compliant providers. Plans must verify licenses, credentials, malpractice history, and more for every provider seeking to bill services. 

Insurers enforce such rigorous enrollment procedures to prevent headaches down the road, like:

  • Paying claims for providers losing their license
  • Provider investigations for inappropriate billing
  • Member complaints about subpar providers

Complying upfront minimizes issues before they start costing the plan big time.

What documentation is part of the process?

The paperwork headache includes:

  • License and education verification
  • Malpractice coverage review
  • Practice information like specialties, office locations
  • Agreeing to the health plan’s contract terms
  • Providing tax identification records

Plans redo verification regularly, requiring updates if information changes. Keeping current and complying with requests is critical for a smooth enrollment relationship.

Providers need to do their part as well when vetting potential networks to join.

While health plans scrutinize providers, provider should be selective about insurance network participation as well. Make sure to validate:

  • A health plan’s reputation with patients and providers
  • Plan design for members
  • Reimbursement rates paid for services
  • Speed and accuracy of claims processing

No one wants to deal with endless claim rejections and unsatisfied members and an efficient carrier relationship will result in just that. 

How can SHP help alleviate this headache?

SHP has automated the Provider Enrollment service by speeding up delivery with accurate, signature-ready documents. In other words, our established relationships with various payers gives us the inside edge to meet payer Provider Enrollment requirements quickly and correctly the first time. Additionally, we track the documents from submission through the approval process, communicating participation status regularly with our clients.

Contact us to learn more and receive a quote.

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