How RCM and Enrollment Teams Impact Your Bottom Line

In any healthcare organization, the relationship between the Revenue Cycle Management (RCM) team and the Provider Enrollment team is vital to ensuring smooth operations and proper reimbursement for services provided. These teams might have different functions, but their goals align: to ensure that providers are paid for the care they offer. When these teams collaborate effectively, the entire organization benefits.

One of the most crucial areas where this collaboration is needed is in the provider credentialing and payer enrollment process. The Payer Enrollment team is responsible for ensuring that healthcare providers are properly credentialed with insurance companies and enrolled in the appropriate payer networks. Without this, the RCM team cannot submit claims properly, delaying payment and potentially causing financial setbacks.

While it is possible to bill a patient’s insurance as out-of-network, this option is not ideal for most healthcare providers or patients. To bill out-of-network, providers must first obtain pre-authorization and verify eligibility before services are delivered. However, many patients’ insurance plans do not cover out-of-network services, leaving them with higher out-of-pocket costs. By ensuring that providers are enrolled with the right insurance networks, organizations can avoid these complications and ensure they receive payment for their services.

The primary goal is straightforward:

• Providers need to be correctly credentialed and enrolled in insurance networks so they can be paid for every service provided.
• Patients should not be burdened with paying higher-than-expected bills because their insurance plan does not cover out-of-network providers.

Equally important is the role of the referral and authorization team in this process. They need to verify insurance coverage carefully, especially since coverage can change from one visit to the next. Relying on outdated or incorrect information can cause unnecessary complications. It’s important that insurance details are re-verified regularly, ensuring that patients aren’t surprised by higher bills when they receive care.

When a clinic bills as “out-of-network,” patients can face substantial financial hardship. Insurance companies often do not cover the full cost of out-of-network services, leaving patients responsible for a large portion of the bill. This situation can lead to surprise medical bills that patients did not anticipate, causing frustration and unnecessary financial stress. This can be avoided by ensuring that providers are properly enrolled and credentialed.

Thankfully, with the implementation of the No Surprises Act, patients are now protected from unexpected out-of-network bills, ensuring that they are only responsible for their in-network costs, even in emergency situations.

Learn more about how this law impacts providers and patients in Madaket’s Definitive Guide to the No Surprises Act here.

Learn more about this federal protection, visit WEDI – No Surprises Act Resources.

The bottom line is that RCM and Provider Enrollment teams need to work closely together. When both teams collaborate, healthcare organizations can ensure proper reimbursement, improve the patient experience, and reduce the risk of surprise billing.

For insights on best practices in revenue cycle management, visit the HFMA’s RCM strategies.

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