dawn anderson session 2 beyond the basics of provider … · 2018. 4. 4. · automation technology...

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Beyond the Basics of Provider EnrollmentSession 2

Dawn Anderson

OBJECTIVES

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Copyright © Verity, a HealthStream ® Company

WHY IS ENROLLMENT SO DIFFICULT?

�Approximately 880,000 physicians in the US

�53% of physicians practice in groups with 5 or more providers

�Employing providers in record numbers

�Timelines



�Volume and complexity

�Lack of automation

�Actively seek solutions to improve efficiency and improve revenue cycle management.


2017 Provider Enrollment Survey

Verity, A HealthStream Company

Provider Enrollment professionals at hospitals, healthcare organizations and medical group practices

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Major Challenges Revealed

Challenges(Respondents were able to check all that applied.)

2017 Survey 2016 Survey

Volume of forms/enrollment to be completed for each provider 37.5% 53.8%

Trouble collecting information from provider needed for enrollment 34.1% 42.9%

Knowing when changes are made within my organization or by a provider 31.0% 28.4%

Keeping providers’ information up-to-date with the payers 25.7% 47.8%

Number of providers being on-boarded each month 25.2% 26.9%

Trouble obtaining log in and/or logging into PECOS 24.4% 30.2%

Number of employees allocated to Provider Enrollment functions 22.8% 29.8%

Lack of automation/software for Provider Enrollment 22.6% 23.6%

Using the most up-to-date forms for payers 18.9% 32.4%

Knowing the specific payer criteria and what is required 16.8% 36.0%

Waiting for the provider to authorize a surrogate 16.3% 12.0%

Complicated forms 13.1% 25.1%


Opportunity for ImprovementTop 10 Opportunities for Provider Enrollment Process Improvement

Very Important

Reduce Enrollment Timeframe 81.2%

Improve Provider Satisfaction 65.2%

Implement Process Efficiencies 64.3%

Automation/Simplify – Reduce Cost & Resources

62.2%

Maintain Provider Directory 57.1%

Dashboard Metrics 52.3%

Provider Data Standardization 48.4%

Enterprise Onboarding Operation 47.8%

Delegated Credentialing 42.9%

Integration with PECOS & CAQH 41.3%


Data Enterprise Solutions Can Create Efficiencies

One fifth of Health Care Organizations have merged credentialing and provider enrollment

operations in the last 24 months.

28 % are unaware of plans, while others are implementing plans in the next one to two years. What is next for your Organization?

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Most organization enroll 100+ providers in 10-29 health plans


When asked how many health insurance networks or plans that their providers are enrolled in, it was found that the most common response was 10-29 which accounted for 60.9% of

responses.


WHY FOCUS ON ENROLLMENT?

�Enrollment = Reimbursement

�Reimbursement = Money

�Thus, Enrollment = Money

Timely enrollment is key to reducing write-offs in revenue cycle.

Hospitals, Healthcare Organizations and Medical Groups are actively seeking solutions to improve efficiency and improve their revenue cycle process.

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WHY FOCUS ON ENROLLMENT?

�Days in A/R due to pending provider Enrollment

�Denial of claims/write-offs due to services rendered prior to enrollment

�Writes offs are lost revenue

Turn Around Time (TAT) assumes days from the initial application until provider is participating (par) with payer.


TIME IS MONEY WHEN ENROLLING PROVIDERS

$6641 in opportunity costs (what a physician could bill)* per day ($1,560,688 divided by 235 = $6641.23)$1500 estimated daily physician cost **

30 new physicians per yearIf you save 1 day in time = $194,7301 day (30 physicians x $6641)= $199,230 – 1 Day x ($1500 x 30 physicians) = $45,000If you save 15 day on your TAT= $2,920,950

TATs can be shortened with implementation of the best practice recommendations in this presentation

*Source: 2016 Merritt Hawkins Physician Inpatient/Outpatient Revenue Survey**Source: StaffCare, A Company of AMN Healthcare –based on average locum tenens data/cost


OTHER FACTORS

�Provider Enrollment OnBoarding Delays

�Onboarding Delays = Lost Revenue

�Provider Enrollment lead time is insufficient

�Provider Delays

�Processing Inefficiencies

�Follow-up with payers is time consuming

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BEST PRACTICES

�Review all information to ensure data match

�Enter all information into your database

�Have a Tracking and Workflow job that kicks off each step of your process automatically and provide alerts

�Use PECOS (Provider Enrollment Chain and Ownership System)


BEST PRACTICES�Ensure CAQH matches your information and

is accurate. Use CAQH ProView to load your data.

�Use Payer Online Web portals, when available

�Maintain tracking numbers of all electronic form submitted

�When submitted paper forms, maintain a copy of everything you submitted and keep accurate records of method of submission.


BEST PRACTICES

�Email or fax paper applications to payers, when possible.

�If original signature is required, best practice is to utilize Fed-Ex or U.S. Post Office flat rate or certified mail to track your package.

�Follow up with payer

�Document, Document, Document

�Log in to portals to check status of applications

�Always ask for copies of approvals or denials

�Relationship, Relationship, Relationships

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WHAT ARE THE CHALLENGES?�Each Health Plan/Network has their own

application and requirements

�Health Plans require regular updates when providers information changes

�Identical data doesn’t always meant the same thing to a medical group and a health plan

�It’s not a linear process

�Checklists sometimes fail

�Lack of communication

�Silos


AUTOMATION TECHNOLOGY

�Integrate with CAQH & PECOS to reduce

processing times and improve efficiencies

�Preferably technology with bi-directional feed

to/from CAQH

�Browser-based portal for providers to access their

own data

�Preformatted Payer forms that auto-populates

�Utilize Payer Web Portals

�Expiration Alerts

�Tracking and workflow tools

�Global Update Tools for mass editing capability



�Form letter and ac hoc report generation

�Track details on all database changes

�Editable data dropdown list with pre-populated lists

�User Defined screens and fields

�Security for powerful and robust control of data access

�Primary Source Verification Tools

�Medicare/Medicaid Opt-Out

�Medicare Revalidation tool

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�Social Security Death Master File

�Tools to support Delegated Credentialing including rosters

�Payer Participating Screen to track payer information

�Contract Management

�Fee Schedules

�Automation of emails to provider of expirables


REPORTING METRICS FOR SUCCESS

�Why is it important?

�What should be measured?

� Application Turn-Around-Time (TAT) from applicant back to Provider Enrollment

� Enrollment Turn-Around-Time (TAT) time from application received by payer to provider participating (Par) with payer

� Claims on Hold due to provider enrollment pending – Total Dollars & by Payers & by Days in A/R


ON-GOING MAINTENANCE

�Reporting capabilities for tracking expiration dates and Recredentialing due dates

�Maintaining CAQH & PECOS

�Successfully submitting Recredentialing applications timely

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PROVIDERS ARE REQUIRED TO MAINTAIN THEIR CREDENTIALS SUCH

AS:

�State License

�DEA

�Board Certification

�Malpractice Liability Insurance

�ACLS/CPR Certifications, Etc.


HOW DO YOU TRACK EXPIRING DOCUMENTS?

�Utilize a software or tracking mechanism to ensure expiring documents do not expire

�Credentialing/Provider Enrollment Software (reporting capabilities)

�Excel Spreadsheets (not recommended, but often used)



�Best practice: request expired documents at minimum 3 months prior to their expiration date

�Example:

• 1st Request 90 days prior to expiration

• 2nd Request 60 days prior to expiration

• 3rd Request 45 days prior to expiration

• 4th Request 30 days prior to expiration

• 5th Request 15 days prior to expiration

• FINAL Request should be made prior to effective date (If you get to this point it is recommended you send a certified letter or email with tracking to confirm the provider did receive your request)

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�Send notices via email/fax/mail/text (determine what works best in your organization)

�Involve the provider’s office manager and or credentialing point person to assist with ensuring the expired document is updated timely


MAINTAINING CAQH

�CAQH is required to be re-attested every 120 days

�180 Days for Illinois Providers

�Any expired documents such as medical license, DEA’s, Malpractice Liability Insurance are required to be updated and maintained in CAQH as well

�Any time a document is updated, you must re-attest CAQH in order for the changes to save


WHAT IF CAQH IS NOT KEPT CURRENT?�If a provider fails to maintain CAQH, the

following could occur:

�Enrollment Delays

�Termination from a health plan at the time of Recredentialing

�Loss in Revenue for non-par status

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MAINTAINING PECOS & PECOS REVALIDATION

Cycle 2 Revalidation:�Cycle 2 revalidation took effect late 2015�Notice begins 6 months prior to due date�If revalidation date is missed, providers will be

deactivated with a lapse in billing�Resources provided by CMS to ensure providers

are not deactivated�http://go.cms.gov/MedicareRevalidation�PECOS Revalidation Notification Center�CMS Correspondence Letter (Note: If provider

is reassigned to more than one group, the notification letter will only be sent to one location.)


MAINTAINING PECOS�Reminders:

�Revalidation is due every 3 years for DME providers and 5 years for all other providers

In addition to maintaining PECOS revalidation every 5 years, PECOS also needs to be updated with the following changes to remain compliant with CMS standards:

�Reassignment

�Ownership or authorized official

�Practice location

�Contact person

�Correspondence address, etc.


RECREDENTIALING �Health plans require Recredentialing every 3

years.

�Provider is typically notified 6 months prior to their expiration date.

�During Recredentialing, the provider will need to submit a new updated application and or ensure CAQH is updated.

�All supporting documents that have since expired since initial Credentialing will need to be submitted again, such as:

�License

�DEA

�Board Certification

�Malpractice Liability Insurance

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RECREDENTIALING

�It is important that all requests are submitted timely prior to the Recredentialing due date.

�If Recredentialing standards are not met, a provider will be terminated from the health plan and or/contract which will cause a lapse in billing.

Questions?

dawn anderson session 2 beyond the basics of provider … · 2018. 4. 4. · automation technology...

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