Medicare Enrollment & Behavioral Health Credentialing

Behavioral health credentialing exploded in 2023 and 2024 as providers could enroll in Medicare for the first time. With a whole new group of provider enrollments starting from scratch, credentialers will likely be juggling towers of documents and data for the foreseeable future. Behavioral health credentialing certainly has a unique and challenging credentialing process. In this blog post, we’ll explore these and how behavioral health practices are adopting technology to prepare for the future.

The Credentialing Process for Behavioral Health

The credentialing process for behavioral health providers is similar, if not the same, as in other care settings. The process spans various stages, including primary source verification, work history and reference checks, background checks, and payer enrollment, potentially extending up to 150 days. At a minimum, these are standard documentation requirements:

• National Provider Identification (NPI) number
• Current Curriculum Vitae (CV)
• Copies of professional state licenses and DEA licenses
• Board certification information
• Professional liability insurance information
• Peer and professional references
• Continuing Medical Education (CME) documents

Providers or organizations must also decide which insurance companies they will accept. This initial choice can significantly impact the behavioral health patient base and operational dynamics. Following this, providers embark on the enrollment phase, a prerequisite for accepting insurance and treating patients.

Many payers require providers to maintain a CAQH ProView profile. CAQH credentialing is designed to alleviate the work for providers because many major payers can access that information without the provider completing a separate application.

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Common Challenges in Behavioral Health Credentialing

Where behavioral health credentialing diverges from typical provider credentialing is Medicare enrollment. Any challenges encountered in the credentialing process can have a significant financial impact on the center when a physician cannot see patients or claims are being denied. According to Merritt Hawkins, one physician’s revenue for an organization is $9,000 per day, so even a few day’s delay can have a significant impact.

Here are some of the most common challenges for behavioral health credentialing and Medicare enrollment:

• Understanding Medicare Requirements: The Center for Medicare and Medicaid (CMS) divides counselors into two main categories: marriage and family therapist (MFT) and mental health counselor (MHC).  CMS has guidelines around each of those relating to education, state licensure, and more.
• Credentialing Documentation: Behavioral health providers must gather and submit extensive documentation for the Medicare enrollment process. This may include proof of licensure, certification, accreditation, malpractice insurance, DEA registration (if applicable), and other supporting documentation. Ensuring all required documents are accurate, up-to-date, and properly formatted can be challenging.
• Navigating PECOS System: Medicare enrollment applications are typically submitted electronically through the Provider Enrollment, Chain, and Ownership System (PECOS). Navigating the PECOS system and understanding how to complete the enrollment application correctly can be challenging, especially for providers unfamiliar with the online enrollment process.
• Application Processing Time: The Medicare enrollment process can be time-consuming, with application processing times varying depending on factors such as the volume of applications, completeness of documentation, and complexity of the application. Behavioral health providers may experience delays in receiving approval for their enrollment applications, which can impact their ability to bill Medicare for services.
• Provider Identification Number (PTAN) Issuance: After approval of their enrollment application, behavioral health providers will be assigned a Provider Transaction Access Number (PTAN) by Medicare. Delays in receiving the PTAN or discrepancies in PTAN assignments can occur, leading to billing and claims submission challenges.
• Understanding Reimbursement Policies: Behavioral health providers must understand Medicare’s reimbursement policies and billing requirements for behavioral health services. This includes familiarity with Medicare’s coverage criteria, billing codes (e.g., CPT codes, HCPCS codes), documentation requirements, and reimbursement rates for different types of services.
• Maintaining Compliance: Once enrolled with Medicare, behavioral health providers must maintain compliance with Medicare’s rules and regulations to continue participating in the Medicare program. This includes ongoing credentialing requirements, licensure or certification status updates, compliance with billing and coding guidelines, and adherence to Medicare’s quality reporting initiatives.
• Navigating Appeals and Disputes: In some cases, behavioral health providers may encounter claim denials, audits, or disputes with Medicare regarding reimbursement or compliance issues. Navigating the appeals process and resolving conflicts with Medicare can be time-consuming and challenging, requiring a thorough understanding of Medicare’s appeals procedures and regulations.

Addressing these challenges head-on with strategic planning and technology can streamline behavioral health credentialing, benefiting providers and patients.

Optimizing Credentialing Through Technology

Adding technology to your credentialing process offers speed and efficiency that cannot be replicated using a manual process. That’s why Infinity Business Insights predicts the global provider credentialing software market, valued at $1.3 billion in 2021, will reach $5.6 billion by 2030. Innovations that offer enhanced accessibility, scalability, and data security are in high demand as behavioral health providers look for ways to streamline the credentialing workflow.

Automation

Automating tedious and time-consuming tasks such as reminding providers to submit documents and checking exclusions databases helps free up time for credentialers and reduces frustration. Leading credentialing software offers a secure online portal for providers to upload the documents their behavioral health providers require and automated email reminders that continue until completed. You can also automate reminders to stay on top of important deadlines, like re-credentialing and expiration. Automated exclusions monitoring and license verification eliminate the website hopping and waiting — again, freeing up valuable time for credentialers to spend on the tasks that require a human touch.

Workflows

With so many moving parts in the credentialing process, it is easy to miss a step or let too much time pass between steps. Credentialing software offers customizable workflows to keep your behavioral health process on track so you can submit a complete credentialing packet the first time. Workflows may include a checklist with assignable tasks, reminders, and dashboards showing outstanding items and due dates.

Transparency

Without credentialing software, it is tough for leadership to have visibility into the process — or for the process to continue uninterrupted if a credentialer leaves the organization. With all documents and information in a central provider profile and all actions tracked in one cloud-based platform, anyone with access can see precisely what has been completed and what is yet to be done for each provider. Dashboards can provide this in a high-level view with the enrollment metrics needed to make business decisions.

Real-Time Reporting

The in-depth reporting included with leading credentialing software provides the insight and visibility you need to keep processes on track and share data with leadership through scheduled reports emailed regularly (daily, weekly, monthly). Every behavioral health provider operates differently and prioritizes different metrics. Make sure to choose software with customizable enhanced credentialing reporting so you can select the data and filters you need, then save the reports you use most often.

By leveraging these technological advancements, the behavioral health provider can enhance efficiency, reduce errors, and maintain compliance, ultimately improving patient care and operational effectiveness.

The Future of Credentialing in Behavioral Health

As the industry moves toward a more efficient future, the role of technology, particularly credentialing software, becomes undeniably central in optimizing operational effectiveness and enhancing patient care quality. The advent of AI to enable efficiency in credentialing processes not only promises enhanced security and accessibility but also paves the way for a more seamless healthcare delivery system. For those looking to advance their behavioral health credentialing process with cutting-edge technology, explore how MedTrainer Credentialing Software can significantly reduce turnaround times and improve accuracy. This is a pivotal step toward operational excellence and unparalleled patient care.