Upfront provider enrollment verification can greatly minimize claim denials

Insurance verification can have a significant impact on a hospital's bottom line. This is why hospitals go to great lengths to ensure a patient's insurance is verified well in advance of an encounter to avoid claim rejection. If the patient is not covered, the procedure is not scheduled.

Similar to when a patient does not have valid insurance and their claim is denied, a patient's claim will also be denied if the provider is not properly enrolled with the patient's insurance plan. Considering a provider can see easily 3-4 patients per hour on any given day, the financial impact of denied claims due to lack of provider enrollment eligibility checks can be significant. Yet despite the financial impact, upfront provider enrollment verification is rarely discussed or practiced within many healthcare organization.

Solving a Seemingly Complex Problem

When you consider a provider participates in as many as 20 – 25 insurance plans, for hospitals and health systems with literally 100s of providers, expecting schedulers to call and verify provider enrollment each time a patient schedules an appointment is not realistic.

Even with the best people in place, without the right software system to manage the provider enrollment process effectively, success will be difficult to achieve. Fortunately, technology is available to greatly streamline this process by providing schedulers with real-time access to your provider's enrollment information. Because not all technology is equal, the following will help when considering options for credentialing and provider enrollment technology.

1. One size does not fit all. Every hospital is unique, therefore, it is important that the vendor you partner with is flexible and offers a customized solution. Look for a vendor that takes the time to understand the workflow of your organization. The vendor should work with you to meet your specific needs.

2. Don't overlook the benefits of the cloud. Cloud-based systems provide "portals" which support data entry and retrieval access to various stakeholders, including scheduling staff. Look for a system that is intuitively easy-to-use and easy-to-understand.

3. For hospitals considering outsourcing, look for a vendor partner that is highly trained and skilled in credentialing and provider enrollment. The partner you select should have an in-depth knowledge of credentialing and provider enrollment and have long-term, established relationships with payers so that they know who to call when follow-up is needed.

4. Lastly, when selecting a vendor, remember that you are also choosing a partner. Take the time to meet face-to-face with the prospective partner before you make your selection; a quick WebEx demonstration is oftentimes not enough.

Given the financial impact of having to write off a case, it's time that healthcare organizations treat provider enrollment verification with the same urgency as they do insurance verification. Similar to a patient not having insurance, if a provider is not enrolled, the procedure should not be performed. With the right processes and cloud-based tools in place, lost revenue due to provider enrollment eligibility issues can be significantly reduced, if not eliminated. How is your organization managing provider enrollment verification?

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

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