payer enrollment fundamentals april 24, 2019
TRANSCRIPT
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PAYER ENROLLMENT FUNDAMENTALSAPRIL 24, 2019
Donna Goestenkors, CPMSM - President
Nicole Keller, MSHM, CPHQ, CPHIT -Corporate Quality Assurance Officer
Team Med Global Healthcare Consulting
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PROGRAM FACULTY
Donna Goestenkors, CPMSM
2
43Years of Service
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PROGRAM FACULTY
Nicole Keller, MSHM, CPHQ, CPHIT
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15+Years of Service
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EDUCATION PARTNERS
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• Describe the important tools needed to assess the effectiveness of the payer enrollment process.
• Identify how to implement best practices to gain enrollment proficiency, improve performance that will positively affect the bottom line.
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OBJECTIVES
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PREARE YOURSELF
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ACTIVITY
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VERBOLOGY
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MSP CORE COMPETENCE
CAREER
Power
PERSONAL/PROFESSIONAL
Effectiveness
SKILLSEfficiency Core:
~Credentialing Management~Privileging Management
~Practitioner Competence Mgmt.{privileging, FPPE, OPPE}
~Compliance Management~Enrollment Management
~Healthcare Quality Data Management~Practice Management
~Managed Care Management~On/Off-Boarding Management
~Office Management~Consulting Management~Document Management
~Merger/Acquisition Management~Lean Management
~Technology Management~Relationship Management~Development Management
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Credentialing
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ENROLLMENT IS NOT…
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DEFINITIONS
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FUNDAMENTALS
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Where is Enrollment performed in your organization?• Credentials Verification Organization• Medical Staff Services Department• Practice Management• Revenue Integrity Department• Executive Contracting• Compliance Department• Billing Department• Outsourced
WHERE…
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What modality do you use to Enroll?• Paper/Manual
• Fillable Forms
• Adobe Acrobat Pro
• Payer Web Portals
• Credentialing Software
WHAT…
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How does your organization Enroll?
• Delegated Agreements with Payers
• Type II NPI
• Type I NPI
HOW…
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How does your organization Enroll?• Prepare/Submit Enrollment Applications
• Individual/Group
• CAQH
HOW…
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Who does your organization Enroll?
Individual vs. Group Provider:• Depends on who the billing will go through (Individual
NPI or Group/Org Tax ID).• If enrolling Group, individual needs to also be enrolled
and benefits are normally assigned to the Group.• Identify your organization’s internal enrollment
processes before starting.• Identify desired health plans to enroll in.
WHO…
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Who does your organization Enroll?
Examples of provider types:• Medical Providers - MD, DO, PA, NP• Behavioral/Mental Health Providers• Home Health Agencies• Durable Medical Equipment (DME) Providers• Radiology/Imaging Providers• Pharmacy Providers• Independent Diagnostic Testing Facility (IDTF)• Dental Providers
WHO..
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How long does the Enrollment process take?• Processing times vary by payer – contact the plan and
ask!• Depending on the payer, can take 30-180 days.• Out of State applications can take longer than In State
applications.
HOW…
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When will the Enrollment process be completed?• Stakeholders
• MSPs/Enrollment Specialists
• Practitioner
• MSP
• Enrollment Specialist
WHEN…
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When do providers need to revalidate?• Medicare – 3-5 years depending on provider type• Medicaids – In State vs. Out of State• Private/commercial payers – can vary, usually follow
Medicare and/or Medicaid guidelines
WHEN…
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WHEN SHOULD I START?
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WHAT IS THE PROCESS?
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WHAT IS THE PROCESS?
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WHAT IS THE PROCESS?
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ENROLLMENT PROCESS MODEL
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ENROLLMENT PROCESS MODEL
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• Expired licensure/insurance• Use of correct forms/versions• Errors/omissions on applications• Missing supporting documentation• Provider type-specific requirements for enrollment• Additional requirements for Out of State enrollments• Signature/date on applications (if applicable)• Lack of response to payer requests for more
information• Responses from providers for additional information• Expired passwords for payer web portals
THINGS TO WATCH FOR…
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Using a Technology Solution• Automate/streamline/expedite
• Increase in productivity
• Reduce/eliminate redundancy
• Reduce reliance on paper
• Reporting capabilities w/stakeholders
• Better communication/transparency
• Informed decision making
TECHNOLOGY BENEFITS…
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Enrollment Management• Federal Requirements
• Health Plan Requirements
• Resources
• Technology
• Stakeholders
MSP VALUE
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Where can you turn for help?• Medicare websites – Medicare.gov, CMS.gov• State Medicaid websites, Medicaid.gov• Decision Health• Directory of US Health Plans – AISHealth.com• Payer Enrollment Institute/Team Med Global
Healthcare Consulting• Sonoma Credentialing Services• NAMSS/State Association’s• Peers
RESOURCES
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POWER THOUGHT!
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SPEAKER CONTACT INFORMATION
Donna Goestenkors, CPMSMTeam Med Global Consulting, LLC
Email: [email protected]: (618) 830-0057
Website: TeamMedGlobal.com
facebook.com/TeamMedGlobal
linkedin.com/DonnaGoestenkors
twitter.com/TeamMedGlobal
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SPEAKER CONTACT INFORMATION
Nicole Keller, MSHM, CPHQ, CPHIT
Corporate Quality Assurance OfficerINCYTE DIAGNOSTICS
Email: [email protected]: (360) 927-5291
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THE MSP YOU ARE MEANT TO BE!
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SERVICE LINE
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SERVICE LINE
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SERVICE LINE
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SERVICE LINE
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Team Med Global Healthcare Consulting
o Payer Enrollment Institute
Research
Field Interviews
Lisa Deterding
o PowerPoint Design Consultant
RESOURCES
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CAREER DEVELOPMENT RESOURCE
Features include: Frequently asked questions by
MSPs Sample job descriptions,
systematic Assessment tools, planning
techniques, and strategies for effective performance
Real-life stories to illustrate specific points
Order your copy today by emailing: [email protected]
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CREDENTIALING TOOL
Order your copy today online by visiting: www.teammedglobal.com
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TMG – NATIONAL PRESENCE
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MSP CREED
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MSP CODE OF CONDUCT
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COLLABORATION MAKES MAGIC
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THANK YOU!
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SERVICE LINE
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SERVICE LINE
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SERVICE LINE
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SERVICE LINE
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Team Med Global Healthcare Consulting
o Payer Enrollment Team
Research
Lisa Deterding
o PowerPoint Design Consultant
RESOURCES
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© 2019 All Rights Reserved
CAREER DEVELOPMENT RESOURCE
Features include: Frequently asked questions by
MSPs Sample job descriptions,
systematic Assessment tools, planning
techniques, and strategies for effective performance
Real-life stories to illustrate specific points
Order your copy today by emailing: [email protected]
54
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CREDENTIALING TOOL
Order your copy today online by visiting: www.teammedglobal.com
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TMG – NATIONAL PRESENCE
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MSP CREED
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MSP CODE OF CONDUCT
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TMG GLOBAL NEWSLETTERS & BLOGS
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THANK YOU!
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