Thought Leadership

New Perspectives To Improve the Credentialing Industry

Category: White Paper

Doctors Without Dashboards

As seen in Exago: Written by Nicole Hitner Things change slowly in the healthcare industry, but according to Newport Credentialing VP Technology David Meier, they are changing—and for the better. Before the Affordable Healthcare Act (ACA) became law in 2010, patients, care provider groups, and insurance companies were in a three-way tug of war over… Read More

As seen in Exago: Written by Nicole Hitner

Things change slowly in the healthcare industry, but according to Newport Credentialing VP Technology David Meier, they are changing—and for the better.

Before the Affordable Healthcare Act (ACA) became law in 2010, patients, care provider groups, and insurance companies were in a three-way tug of war over finances, each party trying to get the highest return on its investment. Although the country’s quest for an optimized healthcare system continues, Meier says the tone of the conversation has moved away from competition and toward patient-centered systems such as value-based care, a more holistic alternative to fee-for-service payment models.

“There has been a major shift in the industry as a whole,” says Meier. “Before, these three groups had their own agendas and didn’t really work well together. Now, provider organizations are working to align with patients’ needs in order to keep them healthy and happy.”

This paradigm shift has had a major impact on healthcare information systems. Now, more than ever, federal regulators are enforcing data integrity standards and holding providers and insurers accountable for their records, putting companies like Newport Credentialing at the center of the action.

Newport Credentialing Solutions produces CARE, a cloud-based credentialing and provider enrollment application complete with workflows, analytics, and business intelligence. Medical groups use CARE to manage their relationships with insurers like MVP and UnitedHealth. Because the providers, or doctors, in each group must enroll with each insurer separately, the recordkeeping is extensive. Not only that, but each insurer has its own requirements for when and how often providers need to update their information, as governmental penalties for inaccuracy are passed down through the insurer to the doctors themselves.

“It’s really become more and more important that the data that we’re providing to the health insurance plans is accurate,” says Meier. “And this is where business intelligence really fits into the whole thing.”

According to Meier, modern solutions like CARE find themselves thrust into an ecosystem of disjointed technologies. Although provider groups are continuing to consolidate into larger medical groups, their backend processes and programs are failing to keep pace. As a result, providers often have no way to visualize or even query their data themselves.

In these conditions, even running simple reports is an ordeal. “Let’s say a medical group wants to see all their providers and the locations where those providers are seeing patients,” Meier offers by way of example. “Usually what happens is they have to put in a request to IT, IT has to go into an approval process that then gets slated for work, and then it takes two or three weeks for them to start working on the order. Maybe it’s eight hours worth of effort. The group needs something tomorrow, but they’re not going to get it for a month and a half. And that’s not exaggerating.”

When Newport comes on the scene, its business intelligence capabilities change all this for the client organization. Where before providers were relying on spreadsheets and black boxes, now they are able to access, visualize, and report on their data. Some even elect to use CARE’s ad hoc reporting tool to build custom reports on the fly.

As exciting as this newfound freedom is for provider groups, Meier sees BI’s impact on data management as even more significant. CARE connects to a variety of platforms including billing, HR, privileging, and central verification office systems. In many cases, these systems do not interface with each other, and their manually-entered data is rife with inconsistencies. As the reporting hub and common link between these disjointed systems, CARE often becomes the “source of truth” for provider groups, writing cleansed data to the other systems in the network.

“Although provider data management hasn’t historically been a central tenet of provider enrollment, we realized early on that it needed to be,” Meier explains. “Organizations need to centralize this data somewhere. It can’t be in a hundred different systems throughout the organization, and you can’t filter on a location if you have fifty different ways of spelling it.” BI by its very nature is compelling healthcare organizations to clean up their data practices.

But BI is also helping Newport speed up some of the bureaucratic processes that have been holding healthcare back in the first place. With hard data their fingertips, CARE agents are able to tell medical groups how long it takes them to, for example, complete a step of the enrollment process and flag possible inefficiencies. “It was taking around 45 days for one of our clients to get information back to us,” relates Meier. “We showed them this because we have the data and, in doing so, we cut that down to about 12 days.”

For Meier and the rest of the Newport team, these kinds of victories are ultimately about providing better care. If healthcare 1.0 was about profit, then healthcare 2.0 is, as Meier puts it, about “prioritizing patient health.”

“There are downstream effects for everybody,” he says. “For us, it’s managing data and making sure that provider data is as accurate as possible.”

Exago is the original producer of this publication.

For Organizational Guidance – A Compass or a GPS?

As seen in Becker’s Health IT & CIO Review: Written by Scott Friesen, CEO, and Patrick Doyle, Senior Vice President, Newport Credentialing Solutions Managing the revenue cycle for healthcare organizations is a complex endeavor. To navigate the many variables associated with successful reimbursement, revenue cycle management is becoming increasingly reliant on data analytics. Understanding which… Read More

As seen in Becker’s Health IT & CIO Review: Written by Scott Friesen, CEO, and Patrick Doyle, Senior Vice President, Newport Credentialing Solutions

Managing the revenue cycle for healthcare organizations is a complex endeavor.

To navigate the many variables associated with successful reimbursement, revenue cycle management is becoming increasingly reliant on data analytics. Understanding which data points to focus on is key to obtaining operational and financial excellence. Just like using a GPS navigation tool is more precise and easier to use than a hand-held compass, managing the complex revenue cycle requires the same kind of advanced tool-set that can normalize and present data in a precise and easy to use manner.

While there are many moving parts in the healthcare revenue cycle, a frequently overlooked component is…
 
 
As seen in Becker's Health IT & ReviewClick here to read the full article.

Becker’s Health IT & CIO Review is the original producer of this publication.
 
 
 

The Invisible Impact of Credentialing: Tip 2

Tip 2: Make Sure All Data is Protected – Not Just PHI.   More than two decades ago, the Health Insurance Portability and Accountability Act (HIPAA) was signed into law. One of its most significant provisions was to create a standard method of protecting patient data, regardless of where it resides. In 2000 additional safeguards… Read More

Tip 2: Make Sure All Data is Protected – Not Just PHI.

 
More than two decades ago, the Health Insurance Portability and Accountability Act (HIPAA) was signed into law. One of its most significant provisions was to create a standard method of protecting patient data, regardless of where it resides. In 2000 additional safeguards were put in place and Protected Health Information (PHI) became the responsibility of everyone in the healthcare sector. As a result…

[click here to download].
 
 

Looking for additional tips?

To download Tip 1, please click here.
 
 

The Invisible Impact of Credentialing: Tip 1

Tip 1: Credentialing Can Disrupt Your Patient Satisfaction Outcomes.   With the advent of Accountable Care Organizations (ACOs) and population health management initiatives, healthcare organizations are increasingly implementing technology and processes to encourage patient engagement. Incumbent in these efforts is the collection of more patient satisfaction data to help yield better decision making to promote… Read More

Tip 1: Credentialing Can Disrupt Your Patient Satisfaction Outcomes.

 
With the advent of Accountable Care Organizations (ACOs) and population health management initiatives, healthcare organizations are increasingly implementing technology and processes to encourage patient engagement. Incumbent in these efforts is the collection of more patient satisfaction data to help yield better decision making to promote lower cost delivery models and better clinical outcomes throughout the communities they serve.

As providers in all healthcare delivery networks strive to enhance patient satisfaction scores, they are all too often burdened by… [click here to download].
 
 

Looking for additional tips?

Over the coming months, Newport will provide a 4 part Tips Series which focuses on the invisible impact of credentialing. Check back soon!
 
 

Advances in Technology Can Significantly Improve the Efficiency and Quality of the Credentialing Process

As seen in Becker’s Hospital Review: Written by Jodie Chant, MPA/HCA, BHSA, CPCS, RHIT, Principal Consultant, Jodie Chant Consulting, LLC Changes in the healthcare industry are placing a growing list of demands on health plans, hospital and health system medical staff services and credentialing departments. In the quest to keep up with increasing regulatory and… Read More

As seen in Becker’s Hospital Review: Written by Jodie Chant, MPA/HCA, BHSA, CPCS, RHIT, Principal Consultant, Jodie Chant Consulting, LLC

Changes in the healthcare industry are placing a growing list of demands on health plans, hospital and health system medical staff services and credentialing departments. In the quest to keep up with increasing regulatory and accreditation requirements driven by the Accountable Care Act (ACA), CMS, The Joint Commission and others, the time left for comprehensive credentialing activities is getting smaller and smaller. Yet, the obligation to ensure patient safety through a thorough, quality-driven credentialing investigation remains the same.

To relieve the time constraints of credentialing, hospitals, health systems and health plans are increasingly enlisting the services of credentials verification organizations (CVOs). A new technology is also growing in popularity, and from what I can see, it is a true game changer for the healthcare industry…
 
 
As seen in Becker's Hospital ReviewClick here to read the full article…
 
Becker’s Hospital Review is the original producer of this publication.
 
 

Are You Billing All You Can For Locum Tenens Physicians?

As seen in Becker’s Hospital CFO: Written by Allyson Schiff, VP of Operations for Newport Credentialing Solutions The demand for locum tenens physicians has increased significantly over the past several years. Today, they are helping to meet temporary physician staffing needs in hospitals, group practices and clinics around the country. In addition to being able… Read More

As seen in Becker’s Hospital CFO: Written by Allyson Schiff, VP of Operations for Newport Credentialing Solutions

The demand for locum tenens physicians has increased significantly over the past several years. Today, they are helping to meet temporary physician staffing needs in hospitals, group practices and clinics around the country.

In addition to being able to fill in for regular physicians when needed, there are plenty of other benefits associated with using locum tenens physicians. For example, significant cost savings can be achieved by not having to employ additional full time physicians, while administrative functions, like malpractice coverage,become the responsibility of the locum tenens group. While the benefits of utilizing locum tenens physicians are plenty, when not managed properly, there are also some risks including the potential for lost revenue…
 
beckers-hospital-cfoClick here to read the full article.
 
 
 
Becker’s Hospital CFO is the original producer of this publication.
 
 

Enrollment Nightmares and Zombie Doctors

As seen in Becker’s Hospital Review: Written by Allyson Schiff, VP of Operations for Newport Credentialing Solutions In honor of Halloween, Newport Credentialing Solutions’ Vice President of Operations, Allyson Schiff, discusses the truly horrifying provider enrollment and credentialing issues that hospitals are constantly faced with. Click to learn how hospitals can protect themselves from wicked… Read More

As seen in Becker’s Hospital Review: Written by Allyson Schiff, VP of Operations for Newport Credentialing Solutions

newport-halloween-story-2In honor of Halloween, Newport Credentialing Solutions’ Vice President of Operations, Allyson Schiff, discusses the truly horrifying provider enrollment and credentialing issues that hospitals are constantly faced with. Click to learn how hospitals can protect themselves from wicked paperwork, zombie doctors, and other frightening issues.
 
 
As seen in Becker's Hospital ReviewClick here to read the full article, if you dare…
 
 
 
Becker’s Hospital Review is the original producer of this publication.
 
 

Five Tips for Achieving Provider Enrollment Success in a Complex Landscape: Tip 5

Tip 5: Know When to Ask For Credentialing Help.   For mid to large size healthcare organizations, especially those with multiple locations, managing credentialing and enrollment in-house can be a time-consuming and costly endeavor.This is especially true when relying on manual methods like paper, Excel tracking tools or email calendar alerts. With the financial implications… Read More

Tip 5: Know When to Ask For Credentialing Help.

newport-credentialing-tip-5
 
For mid to large size healthcare organizations, especially those with multiple locations, managing credentialing and enrollment in-house can be a time-consuming and costly endeavor.This is especially true when relying on manual methods like paper, Excel tracking tools or email calendar alerts.

With the financial implications of not properly managing credentialing and enrollment well known, more and more… [click here to download].
 
 

Looking for additional tips?

Over the previous months, Newport has provided a 5 part Tips Series which focuses on the key elements of a high performing provider enrollment department. Check the rest of our Thought Leadership blog for the other tips!
 
 

Five Tips for Achieving Provider Enrollment Success in a Complex Landscape: Tip 4

Tip 4: Don’t Overlook the Benefits of the Cloud. Cloud computing is becoming increasingly important to the healthcare industry. With the explosion of data from heightened adoption of electronic health records, the cloud offers a cost-effective, scalable solution for storing, accessing, and sharing information.The cloud also facilitates easy and increased cooperation between healthcare providers; which… Read More

Tip 4: Don’t Overlook the Benefits of the Cloud.

Newport-Credentialing-Tip-4Cloud computing is becoming increasingly important to the healthcare industry. With the explosion of data from heightened adoption of electronic health records, the cloud offers a cost-effective, scalable solution for storing, accessing, and sharing information.The cloud also facilitates easy and increased cooperation between healthcare providers; which is necessary for population health.

When housing data on a healthcare organization’s in-house servers, access to information is… [click here to download].
 
 

Looking for additional tips?

Over the coming months, Newport will provide a 5 part Tips Series which focuses on the key elements of a high performing provider enrollment department. Check back soon!
 
 

Five Tips for Achieving Provider Enrollment Success in a Complex Landscape: Tip 3

Tip 3: Avoid Credentialing and Provider Enrollment Mishaps Even with processes in place to ensure credentialing success, things can happen along the way. A provider may miss the deadline to submit information to the designated committee. During peak hiring and busy holiday seasons, the department head may lose track of who is coming on board.… Read More

Tip 3: Avoid Credentialing and Provider Enrollment Mishaps

Newport-Credentialing-Tip-3Even with processes in place to ensure credentialing success, things can happen along the way. A provider may miss the deadline to submit information to the designated committee. During peak hiring and busy holiday seasons, the department head may lose track of who is coming on board. When situations such as these occur, a provider is granted temporary privileges or provisional services. These “Band-Aids” let a provider work for several weeks or even months while hospital employees attempt to get the actual committee meeting and other processes in place necessary to grant credentialing privileges. However, these stall tactics come at a price because… [click here to download].
 
 

Looking for additional tips?

Over the coming months, Newport will provide a 5 part Tips Series which focuses on the key elements of a high performing provider enrollment department. Check back soon!
 
 

Five Tips for Achieving Provider Enrollment Success in a Complex Landscape: Tip 2

Tip 2: Eliminate Insurance Eligibility Denials at the Point of Scheduling When a provider joins a hospital they must apply for privileges to conduct clinical services.This process includes obtaining and validating all of the physician’s credentials including, but not limited to, board certifications, academic background, references, and previous work history.A committee must then approve the… Read More

Tip 2: Eliminate Insurance Eligibility Denials at the Point of Scheduling

Newport Credentialing Tip 2When a provider joins a hospital they must apply for privileges to conduct clinical services.This process includes obtaining and validating all of the physician’s credentials including, but not limited to, board certifications, academic background, references, and previous work history.A committee must then approve the provider (sometimes as many as three or four separate committees) before being granted credentialing privileges. Each hospital has its set times for when these committees meet to ensure a smooth process when providers come on board.

While payer dependent, the average enrollment… [click here to download].
 
 

Looking for additional tips?

Over the coming months, Newport will provide a 5 part Tips Series which focuses on the key elements of a high performing provider enrollment department. Check back soon!
 
 

Five Tips for Achieving Provider Enrollment Success in a Complex Landscape: Tip 1

Tip 1: View Provider Enrollment As a Critical Part of Your Revenue Cycle Credentialing and enrollment are critical business processes within the hospital, physician and allied health provider revenue cycle. When not managed properly they can, and will, negatively impact a healthcare organization’s revenue. If a provider is not enrolled correctly, they will not be… Read More

Tip 1: View Provider Enrollment As a Critical Part of Your Revenue Cycle

Newport Credentialing Tip 1Credentialing and enrollment are critical business processes within the hospital, physician and allied health provider revenue cycle. When not managed properly they can, and will, negatively impact a healthcare organization’s revenue. If a provider is not enrolled correctly, they will not be paid properly. Furthermore, incorrect or poorly managed credentialing and enrollment processes may also put a practice at risk for compliance violations and even liability for false claims.

To ensure every credentialing dollar is collected… [click here to download].
 
 

Looking for additional tips?

Over the coming months, Newport will provide a 5 part Tips Series which focuses on the key elements of a high performing provider enrollment department. Check back soon!
 
 

4 Tips to Avoid Lost Revenue This Summer

As seen in Becker’s Hospital Review: Written by Allyson Schiff Newport Credentialing Solution’s Vice President of Operations Summer has officially begun, and employees across the country are heading out on vacation. For the healthcare industry, which operates business as usual regardless of the season, inadequate staffing coupled with poor management of business-critical processes often negatively… Read More

As seen in Becker’s Hospital Review: Written by Allyson Schiff Newport Credentialing Solution’s Vice President of Operations

Summer has officially begun, and employees across the country are heading out on vacation. For the healthcare industry, which operates business as usual regardless of the season, inadequate staffing coupled with poor management of business-critical processes often negatively impact a hospital’s revenue.

Consider, for example, credentialing and privileging which necessitate on-going management and monitoring. These functions require proactive and ongoing monitoring of licenses, sanctions, exclusions and much more. These processes cannot wait for someone to return from summer break as the financial repercussions of incorrectly enrolling providers with payers are huge. If a provider is not enrolled or credentialing expires, a provider will not be…
 
 
As seen in Becker's Hospital ReviewClick here to read the full article.

Becker’s Hospital Review is the original producer of this publication.
 
 

Billing Begins with Insurance and Provider Enrollment Verification

As seen in AMGA’s Group Practice Journal: Written by Patrick Doyle Insurance verification plays an important role in a practice’s revenue cycle management efforts. When verifications are not managed properly, lost revenue can be significant. In addition to the provider’s time, other investments are at risk of being written off when a patient’s insurance is… Read More

As seen in AMGA’s Group Practice Journal: Written by Patrick Doyle

Insurance verification plays an important role in a practice’s revenue cycle management efforts. When verifications are not managed properly, lost revenue can be significant. In addition to the provider’s time, other investments are at risk of being written off when a patient’s insurance is no longer valid, including materials and time spent on case preparation. This is why practices go to great lengths to ensure a patient’s insurance is verified well in advance of an encounter. If he or she isn’t covered, the procedure isn’t done.

While the financial implications of having to write off an encounter are well known, it is surprising that many practices overlook a process as important as insurance verification—provider enrollment verification. Similar to a patient not having valid insurance, when a provider is not properly enrolled with a health plan, his/her encounters will be written off. Given just how many patient encounters a provider has in a given day, week, or month, the financial impact can be significant. Yet few practices have processes in place for provider enrollment verification as stringent as insurance verification.

Insurance verification and provider enrollment are the start of the revenue cycle. If they aren’t viewed as such, they should be. When scheduling patients, provider enrollment verification must become a standard part of the scheduling process alongside insurance verification. When a patient isn’t covered, an encounter will not occur. Providers should follow this same process when an enrollment is not complete.
 
 
AMGA

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The full version of this article can be found in the June issue of Group Practice Journal, the flagship publication of AMGA. Please click here to view.
 
 

Increase Revenue: Ensure Your Credentialing Department is Properly Staffed For New Hire Season

Ensuring that your credentialing department is adequately staffed to meet the new provider hiring rush is critical to maintaining revenue and increasing physician and patient satisfaction.   Click here to download the three ways Newport helps healthcare facilities like yours handle the on-boarding rush. Ready to learn more? Contact us at info@newport.theadleaf.com to speak with… Read More

Ensuring that your credentialing department is adequately staffed to meet the new provider hiring rush is critical to maintaining revenue and increasing physician and patient satisfaction.

 

Newport Credentialing Increase RevenueClick here to download the three ways Newport helps healthcare facilities like yours handle the on-boarding rush.

Ready to learn more? Contact us at info@newport.theadleaf.com to speak with a Newport representative about improving your revenue.

 
 
 
 

Strategies to Help Hospitals Prepare for Residency Season

As seen in Becker’s Hospital Review: Written by Allyson Schiff, Newport Credentialing Solution’s Vice President of Operations In just a few weeks the feeding frenzy will start as physician and medical residents become available for hire. For large health systems, this can mean the addition of several hundred new providers. In the chaotic rush to… Read More

As seen in Becker’s Hospital Review: Written by Allyson Schiff, Newport Credentialing Solution’s Vice President of Operations

In just a few weeks the feeding frenzy will start as physician and medical residents become available for hire.

For large health systems, this can mean the addition of several hundred new providers. In the chaotic rush to bring providers onboard as quickly as possible, a massive amount of work needs to happen. Adequate staffing, on the part of the health system is critical.

When enrollment processes are not managed properly, lost revenue can result in hundreds of thousands of dollars in a matter of months for a lower level provider. When enrolling highly specialized physicians such as neurosurgeons or plastic surgeons lost revenue can be significantly higher.
 
 
As seen in Becker's Hospital ReviewClick here to read the full article.

Becker’s Hospital Review is the original producer of this publication.
 
 

Key Considerations When Selecting a Credentialing Services Company

As seen in Becker’s Hospital Review: Written by Scott T. Friesen, CEO of Newport Credentialing Solutions Provider enrollment has become increasingly complex. Changes in reimbursement, narrow networks, and risk based contracts have created a new provider enrollment landscape which has left many administrators and providers scratching their heads for answers. For a small provider group,… Read More

As seen in Becker’s Hospital Review: Written by Scott T. Friesen, CEO of Newport Credentialing Solutions

Provider enrollment has become increasingly complex. Changes in reimbursement, narrow networks, and risk based contracts have created a new provider enrollment landscape which has left many administrators and providers scratching their heads for answers. For a small provider group, running the credentialing and enrollment process in-house is a manageable endeavor. However for hospitals and health systems, especially those with multiple locations, it can be a time-consuming and costly endeavor. This is especially true when relying on manual methods like paper documentation and email calendar alerts to run credentialing in-house.

With the financial implications of not properly managing credentialing and enrollment well known, more and more providers are turning to…
 
 
As seen in Becker's Hospital ReviewClick here to read the full article.

Becker’s Hospital Review is the original producer of this publication.
 
 

Healthcare Providers Can Often Overlook Critical Areas in Their Security Plans

As seen in Health Data Management: Written by David Meier, VP of Technology Solutions at Newport Credentialing Solutions With data breach news continuing to top headlines, hospitals and other healthcare organizations are stepping up their data security efforts. IT staff are working diligently to ensure EHR systems, accounting systems, and other patient-related software systems are… Read More

As seen in Health Data Management: Written by David Meier, VP of Technology Solutions at Newport Credentialing Solutions

With data breach news continuing to top headlines, hospitals and other healthcare organizations are stepping up their data security efforts. IT staff are working diligently to ensure EHR systems, accounting systems, and other patient-related software systems are secure.

Meanwhile, with the focus primarily on patient information, one-off areas like credentialing and enrollment are being overlooked, and that’s putting providers—and their identifiable information—at risk…
 
 
As seen in Health Data ManagementClick here to read the full article.

Health Data Management is the original producer of this publication.
 
 

Poorly Managed Provider Enrollment Verification Processes Can Prove Costly

As seen in Western PA Healthcare News: Written by Patrick Doyle, Vice President, Newport Credentialing Solutions In the evolving and complex healthcare landscape, providers are relentlessly looking for new ways to improve revenue as they battle rising costs and shrinking reimbursements. With the financial implications of having to write off an encounter well known, it… Read More

As seen in Western PA Healthcare News: Written by Patrick Doyle, Vice President, Newport Credentialing Solutions

In the evolving and complex healthcare landscape, providers are relentlessly looking for new ways to improve revenue as they battle rising costs and shrinking reimbursements. With the financial implications of having to write off an encounter well known, it is no surprise significant time and effort is being spent on insurance verification. Practices are going to great lengths to ensure a patient’s insurance is verified well in advance of an encounter. If the patient is not covered, the procedure is not scheduled.

With so much time and technology used to help providers avoid upfront insurance eligibility denials, it is interesting to note…
 
 
As seen in Western PA Healthcare NewsClick here to read the full article.

Western PA Healthcare News is the original producer of this publication.
 
 

RCM Perspective: Technology’s impact on credentialing and enrollment

As seen in Becker’s Health IT and CIO Review: Written by Anthony Cottone, Consultant for AtlantiCare Physician Group (APG) I have worked my entire professional career in the healthcare field and have a wealth of experience in physician practice management, medical billing (central billing office), software applications development, information technology management, including electronic medical records… Read More

As seen in Becker’s Health IT and CIO Review: Written by Anthony Cottone, Consultant for AtlantiCare Physician Group (APG)

I have worked my entire professional career in the healthcare field and have a wealth of experience in physician practice management, medical billing (central billing office), software applications development, information technology management, including electronic medical records implementation and integration.

Most recently I served as Director of Revenue Cycle Services at AtlantiCare Physician Group (APG), an organization I regard very highly.

As I begin to close out my career, I am now partially retired working as a consultant for APG following a move to the sunshine state, I can’t help but look back at how the healthcare industry has changed as a result of advances in technology. One area in particular where I personally have seen the benefits of technology (and an area that I believe is not discussed nearly enough) is the credentialing and provider enrollment space.
 
 
Beckers Health IT CIO ReviewClick here to read the full article.

Becker’s Health IT and CIO Review is the original producer of this publication.
 
 

Technology’s Evolving Role in Credentialing And Provider Enrollment

Credentialing and enrollment are critical business processes within the hospital, physician and allied health provider revenue cycle. When not managed properly, they can, and will, negatively impact a healthcare organization’s revenue. With regulatory requirements becoming more and more complex, incorrectly or poorly managed credentialing and enrollment processes also put hospitals at risk for compliance violations… Read More

Credentialing and enrollment are critical business processes within the hospital, physician and allied health provider revenue cycle. When not managed properly, they can, and will, negatively impact a healthcare organization’s revenue.

With regulatory requirements becoming more and more complex, incorrectly or poorly managed credentialing and enrollment processes also put hospitals at risk for compliance violations and even liability of false claims.

For years, credentialing and provider enrollment have been overlooked as an essential component of an effective practice management process. Fortunately, with greater awareness of the impact that these functions have on the financial and compliance aspects of a thriving practice, previous mindsets are changing.

Managing the unmanageable

When a provider joins a hospital, they must first apply for the privilege to work at that hospital. This process includes obtaining and validating all of the physician’s credentials including, but not limited to, board certifications, academic background, references, and previous work history. Next, a credentialing committee (sometimes as many as three or four separate committees) must approve the provider before granting credentialing privileges. Each hospital has its own set times for when these committees meet and bi-laws need to be followed to ensure that a smooth process for on-boarding providers occurs.

Despite processes being in place to ensure credentialing success, issues can arise that will cause unexpected delays. Some examples include a provider missing the deadline to submit information to the designated committee or during peak hiring and busy holiday seasons, department heads lose track of who is coming on board. When situations such as these occur, a provider is granted temporary privileges or provisional services. These “Band-Aids” let a provider work for several weeks or even months while hospital employees attempt to get the actual committee meeting and other processes in place so that they may grant the provider privileges to practice medicine. However, these stall tactics come at a price because payer enrollment, which can take from 90 to 120 days, cannot happen until a physician is successfully credentialed and granted privileges. Since the enrollment process cannot begin until privileges have been granted, there is significant risk of revenue loss because while the physician is seeing patients and he/she can bill for those services, they will not be paid because the provider has not been enrolled with their insurance plans. Bottom line, no enrollment means no payment.

To implement a best practice scenario, practice administrators should begin the enrollment process well before the physician has been granted privileges at the healthcare institution. All of these tasks must be managed based on the rules of each insurance payer. For example, some insurance payers will not allow certification until a week or two before the physician starts. In another example, Medicare will not allow a provider to submit an enrollment application until 60 days before the requested effective date. In this instance, having all the paperwork ready for submission and the applications submitted to the insurance payer in advance of becoming privileged with the healthcare institution minimizes any unnecessary delays or revenue loss.

When considering that most of the larger health systems employ upwards of 1,400 providers, credentialing and enrollment is a highly complex and daunting task. Without the right resources, technology and processes in place to successfully manage the entire credentialing life cycle, enrollment can quickly become unmanageable, and revenue and compliance issues are quick to follow.

For large healthcare providers, managing credentialing and enrollment in-house can be a time-consuming and costly endeavor, especially when relying on antiquated methods such as paper or Excel spreadsheets for tracking. Inadequate staffing is another common issue. These are just some of the reasons why hospitals and large multi-specialty physician groups are choosing to partner with Newport Credentialing Solutions.

The Newport Difference

Newport’s cloud-based credentialing software, CARE, is a true game changer. Developed to help clients proactively manage the increasingly complex credentialing life cycle, CARE is the industry’s first cloud-based workflow, analytics, and business intelligence credentialing software on the market.

The application process for onboarding new providers is very cumbersome and time-consuming. On average a physician will participate in as many as 20 – 25 insurance plans. Leveraging Newport’s cloud-based software the credentialing life cycle is streamlined and efficient. Provider data including names, background information and copies of documentation, are securely stored in CARE. Information is automatically populated into all of the required health plan applications saving significant time. Newport pro-actively monitors all pending applications and conducts any necessary follow-up using their patent pending workflow software to ensure that the enrollment process moves along as efficiently and accurately as possible.

With CARE, clients can quickly view provider status, claims on hold, etc. The cloud-based platform easily depicts where the provider is within the credentialing life cycle. If there are delays, CARE will allow clients to drill down to see what those problems are so they can be quickly resolved. Reports can be generated in real-time to show specific process details such as provider enrollment by payer group, practice locations(s), credentialing, and provider enrollment status, NPI numbers and more. Using the cloud, operations managers have easy access to the CARE system so they can quickly review billing areas under their control and run reports themselves. Finally, users can rest assured that their provider data is secure because all data is securely hosted and encrypted using patented third party encryption software.

Because credentialing and provider enrollment delays will happen, it is important to put steps in place that minimize any foreseeable issues. CARE allows clients to monitor how much revenue is being lost and which providers are the biggest offenders so staff can prioritize follow-up activities. Processes are significantly easier and streamlined with CARE in comparison to trying to maintain spreadsheets or loading data onto a shared drive.

A successful provider enrollment initiative needs to be proactive; this means continuous follow-up on pending applications and claims. Newport offers highly experienced credentialing specialist resources to manage the entire credentialing life cycle.

Newport’s staff has a deep knowledge of the provider enrollment process and has established long term relationships with insurance payers; they understand what is required to manage the credentialing life cycle successfully. With Newport’s cloud-based software, industry defining process and procedures, and highly experienced credentialing specialists in place, providers can look forward to an increase in revenue.
 

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Terrifying tales of credentialing and provider enrollment mishaps

As seen in Becker’s Hospital Review: Written by Allyson Schiff, VP of Operations for Newport Credentialing Solutions In honor of Halloween Newport Credentialing Solutions’ Vice President of Operations, Allyson Schiff, continues her holiday series spotlighting some of the most grotesque credentialing and provider enrollment issues facing hospitals today. As a follow-on to her first article,… Read More

As seen in Becker’s Hospital Review: Written by Allyson Schiff, VP of Operations for Newport Credentialing Solutions

Bat-HalloweenIn honor of Halloween Newport Credentialing Solutions’ Vice President of Operations, Allyson Schiff, continues her holiday series spotlighting some of the most grotesque credentialing and provider enrollment issues facing hospitals today. As a follow-on to her first article, “Medicare revalidations – a horror story in the making,” this next article focuses on hair-raising credentialing and provider enrollment mishaps. Continue if you dare…
 
 
As seen in Becker's Hospital ReviewClick here to read the full article, if you dare…

Becker’s Hospital Review is the original producer of this publication.
 
 

Medicare revalidations, a horror story in the making

As seen in Becker’s Hospital Review: Written by Allyson Schiff, Newport Credentialing Solutions’ VP of Operations While Halloween only comes around once a year, hospitals are constantly faced with truly horrifying provider enrollment and credentialing issues. When not managed correctly, the financial impact can be bone chilling. In honor of Halloween, Newport Credentialing Solutions’ Vice… Read More

As seen in Becker’s Hospital Review: Written by Allyson Schiff, Newport Credentialing Solutions’ VP of Operations

Spider WebWhile Halloween only comes around once a year, hospitals are constantly faced with truly horrifying provider enrollment and credentialing issues. When not managed correctly, the financial impact can be bone chilling. In honor of Halloween, Newport Credentialing Solutions’ Vice President of Operations, Allyson Schiff, kicks off this holiday series by discussing one of the most grotesque provider enrollment issues facing hospitals today, menacing Medicare revalidations.
 
 
As seen in Becker's Hospital ReviewClick here to read the full article, if you dare…

Becker’s Hospital Review is the original producer of this publication.
 
 

Credentialing Implications on Patient Satisfaction

With the advent of Accountable Care Organizations (ACO’s) and population health management initiatives, healthcare organizations are implementing technology and process solutions designed to encourage patient engagement. Incumbent in these efforts is the collection of more patient satisfaction data to help yield better decision making to promote lower cost delivery models and better clinical outcomes throughout… Read More

With the advent of Accountable Care Organizations (ACO’s) and population health management initiatives, healthcare organizations are implementing technology and process solutions designed to encourage patient engagement.

Incumbent in these efforts is the collection of more patient satisfaction data to help yield better decision making to promote lower cost delivery models and better clinical outcomes throughout the communities they serve.

As providers in all healthcare delivery networks effort to enhance patient satisfaction scores, they are all too often burdened by events that occur outside the scope of treatment. Parking convenience, patient wait times, and the perception of a courteous medical staff all impact the patient’s experience and the way they express their level of satisfaction. One often overlooked scenario impacting patient satisfaction is the credentialing and enrollment status of a provider that is assumed – both by provider and patient – to be in a payer’s network.

When a provider’s participation status with a health plan is disrupted – which could stem from a failure to adequately monitor expiring documents, errors in the initial/ re-enrollment process, or failing to identify all locations where that provider will see patients – the patient may face a denied claim for utilizing “out-of-network” services or be told by their health plan that they are responsible to pay higher co-insurance levels than previously disclosed. Since the patient is generally held harmless in these scenarios, most providers will quickly work with the patient and write-off these charges. However, the patient’s experience in these instances is generally unfavorable regardless of the financial outcome or impact they ultimately realize.

What compounds the problem in this scenario is the failure to record the root cause of a patient’s dissatisfaction. Unless a patient takes time to write a narrative describing this scenario, most survey forms will not specifically address credentialing related issues and the patient’s dissatisfaction can manifest in other metrics that are monitored. This leaves the organization with a skewed data set of unfavorable survey outcomes and an inability to take appropriate corrective actions.
 

About the Author

Patrick Doyle is the Vice President of Business Development for Newport Credentialing and has over 20 years of experience in healthcare IT and revenue cycle solutions.

About Newport Credentialing Solutions

Newport Credentialing Solutions is the nation’s premier provider of cloud based software and IT enabled services dedicated to the credentialing life cycle. Newport provides cloud based workflow, analytics, and business intelligence credentialing software and IT enabled credentialing services to some of the largest academic medical centers, health systems, and multi-­‐‑ specialty group practices in the United States. Newport helps clients “Take Control” over their credentialing life cycle by streamlining operations, reducing credentialing related denials, and generating more cash for their organization.

For more information on Newport’s software and service solutions, please contact 516.593.1380 or info@newport.theadleaf.com.

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University of Pennsylvania Health System – Academic Medical Center

The University of Pennsylvania Health System (Penn Medicine) is a world-renowned academic medical center dedicated to discoveries that advance science, outstanding patient care throughout the world, and the education of physicians and scientists who carry on its legacy of excellence. The organization has nearly 2,000 physicians between its primary care network and faculty practice plan.… Read More

The University of Pennsylvania Health System (Penn Medicine) is a world-renowned academic medical center dedicated to discoveries that advance science, outstanding patient care throughout the world, and the education of physicians and scientists who carry on its legacy of excellence. The organization has nearly 2,000 physicians between its primary care network and faculty practice plan.

Like many faculty practice plans and physician organizations that have evolved over the years, Penn Medicine had created and maintained a large number of tax IDs. Greater than 30 different tax IDs were in use with all of the revenue ultimately being owned by the Trustees of the University of Pennsylvania. With the significant increase in Electronic Medical Record (EMR) integration along with increasing regulatory requirements focusing on quality (Meaningful Use, Value Based Modifier, etc. ), the existing structure no longer works. Reporting patient services under different tax ID’s did not properly reflect Penn Medicine’s integrated approach to the care they provide their patients.

Penn Medicine was faced with the enormous undertaking of paring down its faculty practice plan tax ID numbers from 32 to one and needed additional and experienced resources to complete the task within the desired timeframe. Penn Medicine partnered with Newport Credentialing Solutions to manage and complete the task.

Highly experienced staff provides necessary resources

Familiar with Newport and its reputation for excellence in credentialing and provider enrollment, the Senior Director of Patient Accounting at Penn Medicine, Steven Honeywell, enlisted Newport’s services. The project began in February 2015, and needed to be affective with dates of service starting May 1st 2015.

Newport’s deep knowledge of the provider enrollment process and established relationships with payer groups proved to be a huge asset for the project. The consolidation required Newport to work with Penn Medicine’s large number of payers (including Medicare, Independent Blue Cross and all other Blues Plans, Aetna and many others). Newport was involved in the process to create new national provider identification numbers (NPIs) and make sure the group NPI’s and Physicians were correctly associated with our designated tax ID number.

The project was a massive undertaking that required diligent follow-up. If NPIs were not set up correctly in the payers’ systems, the claims would go unrecognized, and potentially not paid. The team at Newport has proven they have the knowledge, the resources, and the follow-through to meet the demands of this cumbersome task.

According to Honeywell, to undertake a project of this size internally Penn Medicine would have had to hire additional staff specifically for the duration of the project. Even with the added resources, without the knowledge and experience that Newport’s staff brought to the table, it would have taken the Penn Medicine team significantly longer.

Spotlight Quote: “Newport brought the much-needed resources and expertise necessary to handle this very demanding project. They work with payers every day along with our internal resources. They know the right contacts at the payers, and they know how the provider enrollment industry works. The staff at Newport are great to work with and very diligent with follow-through. It is clear they know their stuff, and I could not be more pleased with the services Newport provides,” concluded Honeywell.

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The Evolution of Credentialing and Provider Enrollment

As seen in Becker’s Hospital Review: Credentialing and enrollment are critical business processes within the hospital, physician and allied health provider revenue cycle. When not managed properly, they can, and will, negatively impact a healthcare organization’s revenue. With regulatory requirements becoming more and more complex, incorrectly or poorly managed credentialing and enrollment processes also put… Read More

As seen in Becker’s Hospital Review: Credentialing and enrollment are critical business processes within the hospital, physician and allied health provider revenue cycle.

When not managed properly, they can, and will, negatively impact a healthcare organization’s revenue. With regulatory requirements becoming more and more complex, incorrectly or poorly managed credentialing and enrollment processes also put hospitals at risk for compliance violations and even liability of a false claim.
 
 
As seen in Becker's Hospital ReviewClick here to read the full article.

Becker’s Hospital Review is the original producer of this publication.
 
 

AtlantiCare – Hospital Employed Physicians

AtlantiCare Physician Group (APG) provides high-quality, convenient healthcare to communities throughout southern New Jersey. With more than 350 physicians, APG offers a full range of outpatient health services including urgent care, primary care, specialty care and occupational health. This large and growing practice has more than 80 different billing areas comprised of primary care, group practices,… Read More

AtlantiCare Physician Group (APG) provides high-quality, convenient healthcare to communities throughout southern New Jersey. With more than 350 physicians, APG offers a full range of outpatient health services including urgent care, primary care, specialty care and occupational health.

This large and growing practice has more than 80 different billing areas comprised of primary care, group practices, anesthesia, behavioral health, neurosciences and more. Before utilizing Newport Credentialing Solutions’ software and services, APG relied on a billing company to handle its credentialing and provider enrollment processes in addition to other billing responsibilities. The company handled everything from Medicare enrollment to local governmental payers such as Medicaid and all commercial carriers. Their lack of experience in credentialing and enrollment coupled with internal process issues at APG resulted in significant non-payment issues. APG realized it was time for a change.

APG’s Director of Revenue Cycle at the time, Tony Cottone, was very familiar with Newport having worked with the company at another hospital. Based on his recommendation, APG agreed to a one-year trial period during which Newport exceeded APG’s high expectations. Now several years later, Newport continues to provide credentialing and provider enrollment services as well as cloud-based reporting to APG. Processes have vastly improved, revenue has increased, and APG remains very pleased with Newport’s staff and services.

Streamlining processes through automation

The billing vendor APG previously utilized relied on antiquated methods to manage their credentialing and enrollment. They relied on spreadsheets rather than a relational database such as Newport uses.

Data updated on spreadsheets had to be shared via uploading and updating on shared drives.  It was cumbersome and not real-time or easily reportable (like a relational database).  Tracking and prioritizing claims on hold by provider was not integrated and therefore more difficult to coordinate between

AtlantiCare and the billing company that was doing the credentialing. Today these processes are completely automated.

Using Newport’s cloud-based credentialing and provider enrollment software, APG staff quickly view provider status, claims on hold, etc. Reports are generated in real-time to show specific process details such as provider enrollment by payer group, practice locations(s), credentialing and provider enrollment status, NPI numbers and more. Using the system’s cloud-based feature, APG’s operations managers easily look at billing areas under their control and run reports themselves. The process is significantly easier and more streamlined than trying to maintain spreadsheets and loading data onto a shared drive as previously done.

Improved communication and a close working relationship

Internal process management improvements within APG, including greater communication between the recruiting department, medical staff, malpractice insurance, revenue cycle, and operations, have helped to improve processes.

Today APG has one person assigned as the vendor liaison. This person coordinates information from the physicians and feeds it back to the team at Newport who then take over all credentialing and provider enrollment responsibilities. Newport closely tracks automated claims on hold and vigorously works to pursue a resolution. Weekly phone conferences between the APG liaison and Newport staff ensure that everyone is up to date on enrollment and claim status. The relationship between APG and Newport is a true partnership.

According to Cottone, “Poor internal policies and inefficient processes led to lost revenue that equaled millions of dollars a year. After switching to Newport Credentialing Solutions and making internal process management improvements at APG, lost revenue is no longer an issue.”

Highly experienced staff and proven processes maximize revenue

The way healthcare is structured today, physicians have to be enrolled in a large number of plans to get paid. Depending on the insurance carrier, the enrollment process can take months. The billing system has to be set up, the credentialing process started, medical staff privileges verified and granted, malpractice insurance managed, the list goes on. The goal is to begin the process before the physician or allied health providers begin work at the hospital or medical group, and all of these tasks need to be managed based on specific insurance carrier rules. For example, some insurance carriers won’t allow certificates to be done until a week or two before the physician starts. However, having all the paperwork ready and the applications out in advance will minimize any unnecessary delays. If an insurance carrier takes 60 days to enroll a provider, things must be managed accordingly.

APG discovered that if processes are inefficient and inaccurate, there is a very high probability that significant revenue can and will be lost. However, using advanced technology, the staff at Newport know all of the payers and who’s who with the state Medicaid plans. The team at Newport have a system in place for Medicare registration and Medicare facility registration which is extremely valuable when managing the status of the applications.

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1DocWay – Independent Physicians

1DocWay provides telepsychiatry services to hospitals and clinics wanting to increase provider access and create new revenue streams. Trusted by approximately 35 clinicians, psychiatrists and psychologists, the company has delivered more than 22,000 telepsychiatry encounters in 11 states. 1DocWay expects to add 70 new physicians over the next year, so managing the credentialing process in-house… Read More


1DocWay provides telepsychiatry services to hospitals and clinics wanting to increase provider access and create new revenue streams. Trusted by approximately 35 clinicians, psychiatrists and psychologists, the company has delivered more than 22,000 telepsychiatry encounters in 11 states. 1DocWay expects to add 70 new physicians over the next year, so managing the credentialing process in-house is no longer feasible.

Previously 1DocWay relied on one full-time staff member to manage its credentialing process. This person handled credentialing, state licensing, health plan enrollment and more. As the practice grew with the addition of several new physicians each month, the process quickly became unmanageable. Even with the help of additional staff members, the credentialing requirements were much more than the staff at 1DocWay were equipped to handle. 1DocWay realized that outsourcing was a much easier and more cost-effective option.

Proven Processes and Highly Experienced Credentialing Staff

Finding the right credentialing company proved harder than the management team at 1DocWay anticipated. While Internet searches revealed quite a few credentialing companies that focus on state licensing and some that focus on hospital credentialing and privilege, finding a credentialing company that manages health plan enrollments was a much more difficult task. With three potential companies identified, the interview process began. Despite their claims, it was immediately clear that two of the credentialing companies had very limited knowledge of the health plan enrollment process; their ideas, protocols and pricing models did not make sense. However, Newport Credentialing Solutions proved to be a different story.

“After speaking with the team at Newport it was immediately clear they know the credentialing business, and they know health plan enrollments. This is exactly what we were looking for in a credentialing partner. Newport has an affordable price model and a very efficient, well thought out process for getting new physicians enrolled and managing them going forward,” commented Phil Hirsch President, Health Services Division for 1DocWay.

Simplifying the Credentialing Process

Newport’s credentialing services were initially sought to help 1DocWay with the new service line that was joining its telepsychiatry network. The plan to onboard this vast healthcare delivery system is a phased addition of physicians. Seven licensed psychiatrists were first to join, with additional psychiatrists to be added to the 1DocWay telepsychiatry network each month. For every doctor, there are approximately 15 health insurance companies. Each physician must enroll in each of the 15 health plans. The applications are cumbersome and time consuming. Working with the team at Newport Credentialing, what would have been an impossible task to manage in-house is now only a matter of providing the physicians’ names, some background information and copies of documentation. The team at Newport takes care of the rest.

With information in-hand, Newport adds the physician data into its cloud-based software program and can then quickly populate the information into all of the required health plan applications. Newport proactively monitors all outstanding applications and conducts any necessary follow-up needed to ensure the enrollment process moves along as quickly as possible.

According to Hirsch, “The telemedicine practice is different than a brick and mortar practice. Therefore, it requires various processes. The team at Newport took the time to listen to our unique needs, they picked up new concepts quickly and were patient when explaining things to staff at 1DocWay which made for a smooth transition. We couldn’t be more pleased with the credentialing services they are providing.”

Maximizing Revenue

Rapid growth at 1DocWay is expected to continue for the foreseeable future as more physicians take advantage of the benefits telepsychiatry has to offer. Previously this would have required a significant expansion of internal staff to keep up with the back office and administrative functions needed to manage the credentialing process. By outsourcing credentialing to Newport, 1DocWay has eliminated the need to hire additional staff to handle to its growing telepsychiatry network.

Other financial benefits have been achieved by significantly reducing denied claims. Prior to utilizing Newport’s services, denied claims were a significant issue when physicians believed to be in the network were not. Despite a disclaimer on its financial forms stating the patient is responsible for the full cost of service in the event the physician is out of network, 1DocWay does not believe in burdening patients with unexpected charges. Therefore, 1DocWay takes the hit. With Newport, there are no more costly out of network surprises.

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Credentialing Challenges and Opportunities for Independent Physicians

Patrick Doyle, Newport VP of Business Development shares the credentialing challenges and opportunities of Independent Physicians and the newly formed state and federal exchange plans Q. How does the addition of new state and federal exchange plans challenge your practice? A. The addition of new federal and state exchange plans creates a distinct credentialing challenge… Read More

Patrick Doyle, Newport VP of Business Development shares the credentialing challenges and opportunities of Independent Physicians and the newly formed state and federal exchange plans

Q. How does the addition of new state and federal exchange plans challenge your practice?

A. The addition of new federal and state exchange plans creates a distinct credentialing challenge in that it causes independent physicians to constantly stay on top of which plans are their patients joining. Further, independent physicians need to balance the increased patient volume and the corresponding revenue generated from those patients, to the time and cost involved in enrolling themselves with the new exchange plans. If they deem the patient volume and revenue to be significant, it is in their best interest to enroll with those plans as soon as possible.

Q. How does an independent physician identify new state and federal exchange plans?

A. Independent physicians should pay close attention to the types of insurance that their patients have. Often, the physician’s electronic health record (EHR) and practice management system (PM) will allow the physician to run reports so that they can quantify all of their accepted insurances and the revenue tied to each insurance. It is at that point that the physician can identify the new exchange plan and initiate enrollment.

Q. What risks exist to the provider if they don’t stay on top of the new exchange plans?

A. Lost revenue. If a physician is not enrolled with their patient’s exchange plans, the physician risks not being paid for rendered services. It is important to recognize that not having an effective physician credentialing strategy can result in a significant reduction in revenue.

Implementing a comprehensive physician credentialing strategy, whether in-house or with an outsourced credentialing partner, ensures that the physician will be paid timely and correctly.

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Credentialing Challenges and Opportunities for Physician Practices

Patrick Doyle, Newport VP of Business Development shares the credentialing challenges and opportunities of Physician Practices and the newly formed state and federal exchange plans. Q. How does the addition of new state and federal exchange plans challenge your practice? A. The addition of new federal and state exchange plans creates a distinct credentialing challenge… Read More

Patrick Doyle, Newport VP of Business Development shares the credentialing challenges and opportunities of Physician Practices and the newly formed state and federal exchange plans.

Q. How does the addition of new state and federal exchange plans challenge your practice?

A. The addition of new federal and state exchange plans creates a distinct credentialing challenge in that it causes physician practices to constantly stay on top of which plans are their patients joining. Further, physician practices need to balance the increased patient volume and the corresponding revenue generated from those patients, to the time and cost involved in enrolling themselves with the new exchange plans. If they deem the patient volume and revenue to be significant, it is in their best interest to enroll with those plans as soon as possible.

Q. How does an independent physician identify new state and federal exchange plans?

A. Physician Practices should pay close attention to the types of insurance that their patients have. Often, the physician’s electronic health record (EHR) and practice management system (PM) will allow the physician to run reports so that they can quantify all of their accepted insurances and the revenue tied to each insurance. It is at that point that the physician can identify the new exchange plan and initiate enrollment.

Q. What risks exist to the provider if they don’t stay on top of the new exchange plans?

A. Lost revenue. If a physician is not enrolled with their patient’s exchange plans, the physician risks not being paid for rendered services. It is important to recognize that not having an effective physician credentialing strategy can result in a significant reduction in revenue.

Implementing a comprehensive physician credentialing strategy, whether in-house or with an outsourced credentialing partner, ensures that the physician will be paid timely and correctly.

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FOX Rehabilitation – Non-Physician Providers

FOX is a private professional practice of physical, occupational, and speech therapists that provide proactive, evidence-based rehabilitation services in the home and senior living community settings. This rapidly growing practice has more than 850 clinicians in nine states. Previously FOX’s credentialing was handled in-house. A manager and two specialists handled the entire credentialing lifecycle including all… Read More

FOX is a private professional practice of physical, occupational, and speech therapists that provide proactive, evidence-based rehabilitation services in the home and senior living community settings. This rapidly growing practice has more than 850 clinicians in nine states.

Previously FOX’s credentialing was handled in-house. A manager and two specialists handled the entire credentialing lifecycle including all new enrollments, re-validations, re-certifications, and any new group establishments with various plans. Without system capabilities in-house and adequate staffing, it became increasing difficult for the staff to manage and maintain the credentialing process. FOX quickly realized that outsourcing was a much easier and more cost-effective option.

The credentialing company FOX initially selected offered a very appealing low price tag but quickly fell short of FOX’s expectations. After transitioning the entire function to Newport Credentialing Solutions, FOX now has a highly trained staff that can keep up with the company’s rapid growth.

A Collaborative Effort Helps Streamline Processes

The transition to Newport was very easy. After a meeting between staff, Newport developed all of the processes which were tailored to address FOX’s unique requirements. It was a collaborative effort that went very smoothly; Newport listened to FOX’s requests and made things happen with no hesitation.

The relationship between FOX and Newport is a real partnership. A Newport representative is onsite up to three days per week managing all of FOX’s new providers (FOX averages 20 new hire clinicians a month). The FOX liaison handles gathering all information necessary to make a completed packet for enrollment; Newport takes over all enrollment processes from there.

“The biggest benefit of our Newport relationship is the resources to keep up with FOX’s rapid growth and highly demanding credentialing requirements,” said Neil Weisshaar, VP of Information Systems at FOX Rehabilitation. “There is a sense of security in knowing that our credentialing process is in excellent hands. Newport’s staff is highly trained and skilled which means we can focus our energy on other aspects of the business.”

Expert Staff Eliminate Resource Constraints, Save Money

Since partnering with Newport, FOX was able to reduce the number of personnel needed to manage credentialing. Only one coordinator remains, serving as the liaison between Newport and the practice. Newport handles all credentialing processes. As a result, the administrator can provide additional resources to other areas of the practice in addition to her vendor relationship role. Cost savings were achieved through the elimination of two positions.

An unexpected benefit of outsourcing is the elimination of seasonal staffing issues. Because credentialing is a process that temps cannot fill, staffing obligations fall short when someone is on vacation. An outsourced billing partner, on the other hand, has to maintain a certain level of service no matter what the season.

“I am a huge proponent of outsourcing having witnessed the benefits of it first hand. Of course having the right partner is essential, and we’ve found that with Newport,” said Lina Monterosso, VP Revenue Management at FOX Rehabilitation. “The staff at Newport took the time to understand our business and the unique workflow of FOX and developed a program that meets our particular needs. Their staff knows credentialing and are on top of everything, which means one less thing we have to worry about.”

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MGMA Connexion’s Magazine – What Lies Beneath the Surface

Reassessing your credentialing process could mean more money in your practice. Effective credentialing processes represent more than gaining approval from payers; they have a direct impact on your revenue cycle and physician alignment success. Yet many industry professionals lack the tools to create effective credentialing processes and might not have the necessary support from industry… Read More

Reassessing your credentialing process could mean more money in your practice.

MGMA ConnexionEffective credentialing processes represent more than gaining approval from payers; they have a direct impact on your revenue cycle and physician alignment success. Yet many industry professionals lack the tools to create effective credentialing processes and might not have the necessary support from industry executives to implement them. A deeper assessment of what the credentialing process represents — and how it can affect your bottom line — can provide the right incentives for change.

“The problem is that many professionals are in a reactive mode when it comes to credentialing,” says Donna Knapp, MA, FACMPE, independent consultant, MGMA Health Care Consulting Group. “It should be a continuous process with dedicated resources.”

Industry shifts have prompted more practice managers to recognize the importance of timely credentialing processes. A growing number of people acknowledge that by reducing the credentialing timeframe and obtaining Provider Identification Numbers (PINs) faster, you are able to bill for claims that would otherwise be written off with a slower credentialing process. For example, Medicare does not allow you to retroactively bill for claims unless you have a PIN.

Decreasing reimbursement, rapidly increasing costs, health information technology and the popularity of accountable care organizations (ACOs) have facilitated clinical, operational and financial integration in recent years. Prior to passage of the Patient Protection and Affordable Care Act, healthcare organizations (both hospital- and physician-owned) operated almost exclusively on a fee-forservice model, which can be likened to an all-you-can-eat buffet that rewarded providers for the number of services provided, not the clinical outcome of those services. The rise of ACOs prompted a gradual change in clinical, operational and reimbursement delivery in which some providers are reimbursed for the quality and successful clinical outcomes of their efforts.

As a result, hospitals and physician groups have begun to align in various forms of ACOs or integrated delivery networks to facilitate the shift to a fee-for-quality model that includes quality and clinical outcomes. For example, Kaiser Permanente, Mayo Clinic and Geisenger have had success with their fee-for-quality reimbursement models, which many large health systems are trying to emulate, according to industry experts.

The ability to optimize the credentialing process with operational and financial metrics is an essential component to this success. For example, data can be used to assess the days in enrollment (DIE) calculation for delegated and non-delegated payers. The ability to link gross charges to in-process credentialing applications, workflow tools, robust reporting, and analytics will facilitate physician alignment strategies, improve productivity, reduce credentialing timeframes and generate incremental revenue for healthcare organizations.

“Physician and allied health provider credentialing requirements have been overlooked by most hospitals and physician organizations,” says Pam D’Apuzzo, president, RR Health Strategies, a consulting group that specializes in physician practice management, coding and compliance. “This has led the OIG [Office of Inspector General] to scrutinize incident-to services. Organizations can mitigate their risk by using robust software to credential and bill for their services in a compliant manner.”

The number of hospital professionals who have initiated efforts to acquire and/or merge with other hospitals and physician organizations to reduce costs and improve clinical outcomes is on the rise, according to published reports. Hospital mergers and acquisitions activity increased 33 percent in 2010 from 2009, according to Healthcare Finance News. 1 Drilling down, 980 healthcare merger and acquisition deals valued at $227.4 billion took place in 2011, according to Modern Healthcare. 2 And many of those deals included physician medical groups.

Although we are seeing an increased interest in physician practice and hospital integration, history shows that some executives might not understand the operational and financial implications of setting up the robust billing, credentialing systems and operations required to successfully execute a physician-alignment strategy. As a result, many hospital professionals are seeing an increase in physician-related denials, frustrated doctors and lost revenue. For example, many see that credentialing denials are not easily reversed by payers and represent a loss of valuable revenue.

Credentialing

Credentialing requirements and challenges have been part of healthcare operations for decades, but market pressures have emphasized the need for efficient programs to capture available revenue and ensure workforce efficiencies. A dramatic increase in physician onboarding efforts and regulatory complexities from health plans and credentialing locations (for example, cross-credentialing providers at multiple or all locations) have forced professionals to seek workforce efficiencies, such as reducing administrative denials to collect all revenue.

“Having a robust workflow and analytics software solution that is tied to key performance metrics ensures that we are proactively managing our credentialing process,” says Motti Edelstein, director of managed care at North Shore – LIJ Health System, N.Y. Those metrics include provider-related denials, “collecting every dollar owed to our organization and ensuring that we are adequately staffed to handle provider growth,” he adds.

The state of credentialing software is a prime example of an industry failure to connect the credentialing and revenue cycles. In the late 1990s, software companies developed products that reduced the data-entry time needed to credential a physician by allowing doctors to create a database of physician demographic data and auto-populate applications from the same database. This reduced the processing time to submit all applications from approximately 40 hours to four hours. However, these products do not show how credentialing affects the revenue cycle.

More than paperwork

Healthcare professionals need to understand the different segments of the credentialing life cycle to gain perspective on the larger operational and financial processes.

They include:

  • Human resources (HR)
  • Hospital credentialing/privileging
  • Physician credentialing
  • Revenue cycle

If healthcare professionals fail to view the credentialing life cycle as an integral component of the revenue cycle, they will see increased denials, frustrated physicians, fragmented operations and lost revenue.

Ideally, physician credentialing will be considered in the following light:

  • It is an integral component of the revenue cycle, not a separate and siloed department.
  • It is one of the first steps in the revenue cycle and considered a continuous process.

Physician credentialing should be aligned with the HR and hospital credentialing process in these ways:

HR works closely with the hospital and physician credentialing departments to set a start date, integrate the hiring, privileging and physician credentialing process into one seamless process.

After a physician is hired, HR shares the news with the hospital credentialing department to initiate primary-source verification services.

Working concurrently, HR and credentialing department personnel tell the medical privileging committees/boards how many physicians will be up for review and privileging approval. If there are multiple medical privileging committees/boards in your organization, inform them in advance. Consider increasing the frequency of committees/ board meetings. Every day that passes without privileges means that physicians cannot see patients to generate revenue.

After a physician is hired and the medical privileging committee/board review is underway, HR and hospital credentialing department personnel ask the physician credentialing department to begin the data collection process. Collect as much demographic information and primary-source documentation as early as possible because there is significant overlap with the data these groups need to conduct their respective jobs. By leveraging HR and credentialing department data collection efforts, physician credentialing department personnel can prepare all credentialing documentation in advance and have enrollment applications ready for submission to payers once a physician is granted privileges.

Incorporate revenue-cycle concepts into physician credentialing to identify revenue loss and incremental revenue opportunities. Physicians are often granted privileges to practice at hospitals before they are enrolled with an organization’s insurance payer. Although this might fill the need for a specialist’s services, there is a negative revenue impact for the organization. For example, a physician starts seeing patients June 1 but has not been enrolled with the 20 insurance payers by the physician credentialing department. This physician generates gross charges of $5,000 in one day and $400,000 in gross charges over the course of 120 days. Now apply that scenario to 10 physicians and the total gross charges during that 120-day period is $4 million. Keep in mind that the physician credentialing department takes at least 120 days (four months) to obtain a PIN for all 20 insurance payers.

If the organization’s gross collection rate is 30 percent, the expected net cash translates into $1.2 million. However, many insurance payers do not retroactively reimburse for services conducted without a PIN, so the organization is faced with a $1.2 million write-off. If 50 percent of insurance payers retroactively reimburse, this still translates to a $600,000 write-off. Create robust metrics to identify, track, trend and manage the physician credentialing life cycle. The following metrics should be considered standard practice in any physician credentialing department:

  • Total physician credentialing opportunity: Total physicians x total payers x total locations* = Total opportunity
  • Total participating status: Total PINs / total opportunity
  • Total non-participating status: Total nonparticipating statuses / total opportunity
  • Total in-process status: Applications in the process of being granted PINs / total opportunity
  • Total financial impact of in-process applications: What is my gross charge impact, what is my net cash impact, how do my in-process applications affect my cash on hand, accounts receivable (A/R), etc.?
  • DIE — non-delegated payers: Total number of elapsed days from the time an application was submitted to an insurance payer compared with a standardized non-delegated metric (90 to 120 days).
  • DIE – Delegated payers: Total number of elapsed days from the time an application was submitted to an insurance payer compared with a standardized delegated metric (30 to 45 days).

Use physician credentialing workflow tools similar to those used in A/R and revenue cycle management to reduce credentialing timeframes, increase productivity and generate more cash. Recommendations for this department:

  • Create dynamic work lists that focus on the physicians and payers who generate the most revenue. This approach might be controversial for multispecialty groups but can help maximize the 80/20 rule and ensure that the majority of top-performers are fully enrolled.
  • Establish productivity tools to gauge credentialing specialist activities and ensure these activities are geared toward PIN completion. Develop productivity benchmarks and baselines to improve overall productivity. Industrywide productivity metrics do not exist for physician credentialing.

Physician credentialing needs robust reporting and analytics to better understand how departments are performing, identify process breakdowns and implement corrective actions.

Robust and easy-to-use reporting and analytic tools allow healthcare professionals to understand how their credentialing departments are performing. Most credentialing software companies provide limited reporting but do not link charges to in-process applications or DIE calculations that highlight payer performance.

Robust data analysis tools must be used during the physician credentialing life cycle so that professionals can see how their credentialing departments are performing.

When an operational process breakdown is identified, immediate corrective action should occur. For example, a credentialing department will compile a credentialing application and give it to a physician for signature in a short period of time. However, occasionally a physician is late returning the signed application. This delay, while inconsequential to the physician, has a real and direct revenue impact for the organization. By tracking and trending this process in the credentialing life cycle, the department can tell the physician how the delay affects the overall bottom line. When you identify a financial process breakdown, implement immediate corrective action. If a physician is delinquent in providing a signed signature page to the credentialing department but generates $5,000 of gross charges on a daily basis, analytics can identify the financial impact of that delinquency, which could prompt the physician to return the page sooner.

Analytics allow administrators to take the anecdote out of physician credentialing and compile statistical and financial data that can be used to provide incentives for physician adherence. Robust analytics can also be used with payers. Healthcare professionals can show specific examples of when payers have been delinquent in processing their physician credentialing applications. For example, healthcare professionals can identify how long it takes each payer to credential their physicians. If payers are taking longer than contractually obligated, show how the behavior affects your bottom line and use the data to negotiate better credentialing guarantees and/or contracted rates.

“Credentialing software can also help you identify breach of contract,” Knapp adds. “I don’t think people use this enough to keep payers honest with what they’ve told us they will do.”

As the healthcare environment shifts and changes, professionals must understand that if their physicians are not credentialed correctly, groups will not be paid correctly, and physicians will not be fully integrated with their healthcare organizations. The implementation of a clearly defined physician credentialing life cycle that encompasses physician credentialing metrics, workflow tools and robust reporting will result in a seamless hospital/ physician alignment strategy and increased net revenue.

Notes:

1 Healthcare Finance News – Hospital M&A Activity Jumped 33 Percent is 2010 – healthcarefinancenews. com/news/hospital-ma-activity-jumped-33-percent-2010

2 Modern Healthcare – M&A Activity Stayed Strong in 2011, Levin Says – modernhealthcare.com/ article/20120120/NEWS/30120996

 

About the Author

Scott T. Friesen is the CEO of Newport Credentialing Solutions and has over 12 years of healthcare experience in the hospital and faculty practice setting.

About Newport Credentialing Solutions

Newport Credentialing Solutions is the nation’s premier provider of cloud based software and IT enabled services dedicated to the credentialing life cycle. Newport provides cloud based workflow, analytics, and business intelligence credentialing software and IT enabled credentialing services to some of the largest academic medical centers, health systems, and multi-­‐‑ specialty group practices in the United States. Newport helps clients “Take Control” over their credentialing life cycle by streamlining operations, reducing credentialing related denials, and generating more cash for their organization.

For more information on Newport’s software and service solutions, please contact 516.593.1380 or info@newport.theadleaf.com.

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Re-Defining Physician Credentialing Management Strategies

Increased M&A activity and physician alignment strategies has caused an unprecedented increase in physician on-boarding. Current physician credentialing management strategies are not equipped to handle this volume and require a shift from a “one to many” management structure to a “team based management structure.” Making this management shift will enable managers to increase specialization, scalability,… Read More

Increased M&A activity and physician alignment strategies has caused an unprecedented increase in physician on-boarding. Current physician credentialing management strategies are not equipped to handle this volume and require a shift from a “one to many” management structure to a “team based management structure.” Making this management shift will enable managers to increase specialization, scalability, and departmental stability.

Background

Today’s healthcare industry is undergoing unprecedented change. Decreasing reimbursement, soaring costs, the implementation of Healthcare IT initiatives (HIT), and the hotly debated Affordable Care Act (ACA) and its most recent manifestation, Accountable Care Organizations (ACOs), have converged to re-­ignite our health policy and economic discourse. Comprising approximately 18% of the gross domestic product (GDP), ideas on how to best manage the unknown future of US healthcare has generated many new and often radical solutions.

With the Patient Protection and Affordable Care Act only 11 months away from its 2014 start, the convergence of decreasing reimbursement, rapidly increasing costs, HIT, and the ACO model is playing itself out in the form of clinical, operational, and financial integration. Prior to the ACA, healthcare organizations (both hospitals and physicians) were operated and reimbursed based on a “fee for service” model. This “all you can eat” operational and reimbursement model rewarded hospitals and physicians by reimbursing the number of services provided rather than on the clinical outcome of those services. However, with the implementation of the ACO model, a sea shift in clinical, operational, and reimbursement delivery has occurred and both hospitals and physicians are now looking at reimbursement models based on the quality of care and the successful clinical outcomes of their efforts.

M&A Activity

In order to best facilitate the shift from a “fee for service” operational and reimbursement model to a “fee for quality” model (which links quality and clinical outcomes to financial reimbursement), many hospitals and physician groups have begun to morph themselves into various forms of ACOs or Integrated Delivery Networks (IDNs). Viewed as a way to improve clinical outcomes and reduce costs, many hospitals have begun significant efforts to acquire and/or merge with other hospitals and physician organizations. According to Healthcare Finance News, hospital M&A activity increased 33% in 2010 from 2009. 1 Further, according to Modern Healthcare quoting a study conducted by Irving Levin Associates (Norwalk, CT), 980 healthcare merger and acquisition deals valued at $227.4 billing took place in 2011. 2 “Among the healthcare sectors announcing 100 deals or more in 2011…” physician medical groups comprised “107 deals.”

This increase in M&A activity has caused many hospitals to look to integrate with as many physician groups as possible. However, what many of these hospitals have failed to realize is that despite integrating these physician practices into their healthcare organizations, many hospitals do not fully understand the operational and financial implications of setting up robust billing and credentialing systems and many hospitals do not have the expertise, staffing, or capital budgets to successfully execute on their physician alignment strategies. As a result, many hospitals are finding an increase in physician related denials, frustrated physicians and most importantly, lost revenue.

Adapt to Meet Growing Needs

The increase of M&A activity has caused many healthcare organizations to assess whether their current methods of managing their physician on-­boarding and credentialing life cycle continue to be effective. Prior to the increase in M&A activity, the physician on-­boarding and credentialing life cycle was managed by loosely affiliated departments across the health system. While their goal of bringing a provider into the healthcare organization are similar, various departments such as business development, human resources (HR), medical staff services and provider enrollment worked independently and rarely communicated efficiently or effectively.

Taken one step further, despite working as independent departments, because growing the rosters of employed providers is on every CEO’s 2013 strategic agenda, medical staff services and provider enrollment departments have seen a dramatic influx of new providers. In situations played out again and again, the business development department acquires a group practice, the HR department manages all of the group practice’s employment paperwork, but the provider is not `privileged or enrolled in a timely or efficient manner. The reason is for the inefficiency is simple. Traditional provider enrollment management techniques do not account for increased volume, growth, and complexity. The result, unfortunately, is that medical staff services and provider enrollment departments have become stretched, overworked, and inevitably fall behind. And, when this occurs, the healthcare organization lose valuable revenue dollars.

Traditional Physician Credentialing – “One To Many”

Traditionally, physician credentialing departments have not experienced high rates of growth and as such, have managed their providers in a one to many management structure. In the one to many management structure (as depicted below), a single physician credentialing specialist manages every component of a large number of providers and their physician credentialing life cycle.

This management structure has worked in the past because the volume and complexity of physician credentialing did not necessitate an alternative. Providers practiced at one or two locations, would only participate with 20-­25 health plans, and would have successful, long-­term careers.

However, in today’s high growth world of healthcare M&A, healthcare organizations are acquiring more and more hospitals and physician groups, physicians are being cross credentialed/enrolled across all healthcare facilities and new physicians are coming on-­board on a daily basis. Additionally, a shortage in physicians has necessitated an increase in the hiring of allied health providers. In order to address this risk, it is critical that physician credentialing managers re-‑assess the one to many management structure.

One issue with the one to many management structure is operational risk. By having one physician credentialing specialist manage every aspect of a large number of provider’s enrollment, there exists a centralization of domain expertise. This centralization of domain expertise works well when the physician credentialing specialist is able to stay on top of all of her duties. However, when that physician credentialing specialist becomes sick, is out on medical leave, is on vacation, falls behind on her work, or quits, the work for all of the providers that she is managing comes to a screeching halt. This poses a significant risk to both work continuity and revenue.

A second issue with the one to many management structure is scalability. Understanding that physician credentialing specialists are falling further and further behind due to the increasing number of providers coming on-­board, it is very difficult to scale physician credentialing staff to meet growing operational demands. By managing every aspect of a large number of provider’s enrollment, it is critical to hire physician credentialing specialists with deep expertise and experience. Further, it is critical that physician credentialing specialist provide value from day one. However, as many managers know, finding physician credentialing specialists with deep expertise is often challenging. As a result, management is left with no choice but to hire credentialing specialists with less experience and hope for the best.

An Alternative – Team Based Provider Enrollment Management – “Many To Many”

The response to concerns regarding the one to many management structure is a team based management structure. Taken from the successful team based management techniques used in revenue cycle management, the team based management structure creates specialized teams to manage each of the specific tasks of the credentialing life cycle.

As the illustration depicts above, rather than have one person manage a large number of providers (and all of the risks that accompany that structure), task based teams are created. These teams are created based on each task of the credentialing life cycle. For example, one team might be a data entry team, a par/non-­par team, an initial CAQH and CAQH re-attestation team, an applications processing team, a credentialing follow up team, or a re-­credentialing team. Each team should be managed by a team lead and in turn, the team lead should be managed by a manager or director.

The benefits of a team based management structure is specialization and increased efficiency. Consider Henry Ford’s pioneering approach to car manufacturing. Each team was assigned a task and by conducting the same task again and again, the teams became specialized and quicker at their tasks. This also applies to the credentialing life cycle. By enabling someone to conduct data entry for new providers all day long, or when they do credentialing follow up all day long, they gain specialized domain knowledge and become faster at the specific task.

Further, by managing your credentialing life cycle in a team based management structure, you create a scalable foundation upon which to growth your credentialing enterprise. Refer back to the Henry Ford model. When demand for his cars increased, all Ford had to do was hire additional people and train them on one task. The same applies to credentialing team based management. When provider volume increases, rather than having to find and train a highly experienced credentialing specialist to manage all aspects of the credentialing life cycle, all you have to do is add additional staff and train them on the one task. The results are quicker transition, a quicker learning curve, and greater departmental stability.

Finally, a team based management structure provides stability and increased morale in your department. In the team based model, if a data entry specialist leaves your department, you only have to find a new data entry specialist, not a highly skilled credentialing specialist. In addition, by breaking down what is often seen as an overwhelming avalanche of work into small, manageable tasks, your staff is able to easily understand what needs to be done and set their mind toward accomplishing that task. The concept of “accomplishable tasks” dramatically increases staff morale both for the individual staff member as well as for the entire department.

Results – So What?

So how does the team based management structure compare to your credentialing department? Do you see the same problems that have been mentioned above and do you also see the benefits of the task based approach?

The “So What?” is simple. The dramatic increase in work associated with increased provider on-­boarding has created an environment which cannot be sustained. Smart managers have to find a way to easily scale their departments into specialized teams. Those that consider the benefits of a team based approach will experience all of the benefits mentioned above and in turn, will gain increased control over their departments and their careers.

About the Author

Scott T. Friesen is the CEO of Newport Credentialing Solutions and has over 12 years of healthcare experience in the hospital and faculty practice setting.

About Newport Credentialing Solutions

Newport Credentialing Solutions is the nation’s premier provider of cloud based software and comprehensive services dedicated to the physician credentialing life cycle. Newport’s industry defining, patent pending software and services enables clients to meet the operational and financial demands of a re-defined Credentialing Life Cycle.

For more information on Newport’s software and service solutions, please contact 516.593.1380 or info@newport.theadleaf.com.

Download

Click here to download the PDF.

Re-Defining Physician Credentialing Software – A New Approach

The upcoming reimbursement shift from “fee for service” to “fee for quality” has generated an increased focus on population health management. In order to ensure a sufficient clinical delivery base, healthcare organizations have begun to consolidate clinical providers at an unprecedented rate. Current credentialing software products are not equipped to handle the complexities of a… Read More

The upcoming reimbursement shift from “fee for service” to “fee for quality” has generated an increased focus on population health management. In order to ensure a sufficient clinical delivery base, healthcare organizations have begun to consolidate clinical providers at an unprecedented rate. Current credentialing software products are not equipped to handle the complexities of a highly distributed, multi-provider, quality driven reimbursement model. Credentialing software must offer an open and revenue centric solution which empowers healthcare organizations to meet the operational and financial demands that population health management requires.

Background

Today’s healthcare industry is undergoing unprecedented change. As a result of the Affordable Care Act (ACA), CMS and commercial payers are moving from a “fee for service” reimbursement model to a “fee for quality” model. One of the primary ways that healthcare organizations are looking to capitalize on the “fee for quality” reimbursement model is to move toward population health management. Defined roughly as providing the complete continuum of clinical care for a geographic population from pre-admission wellness, to service line clinical delivery, to post discharge wellness follow up, the goal of population health management is simple: keep people from having to go to the hospital and in the event that they have to go to the hospital, provide the right care across all specialties so that once they are discharged, they do not have to go back to the hospital. In response for successfully accomplishing the above, any cost savings that are attained will be shared between CMS/commercial payers, and the healthcare organizations/providers.

The move to population health management has forced healthcare organizations to ensure that they have the appropriate number of primary care and specialty providers in order to successfully treat their geographically based patient populations. This in turn has had a dramatic effect on the revenue of healthcare organizations and has gained the attention of every healthcare leader in the country. Whereas healthcare leaders were previously concerned primarily with core revenue cycle concepts including scheduling, insurance verification, authorization, charge capture, medical coding, and accounts receivables follow up, healthcare leader’ attention is now focused on the direct linkage of provider on-boarding, linking those providers to the appropriate payer(s), and identifying the financial impact of those linkages to their ability to collect on their population health delivery initiatives. From a credentialing and provider enrollment perspective, healthcare leaders are realizing that their current credentialing software capabilities are limited at best and that new alternatives are critical to successfully maximize their shift toward population health management.

Population Health Management and Provider Credentialing Software

In order to understand the impact of population health management on the credentialing
software industry, we should first look at how healthcare organizations are a) hiring more and more providers to meet a critical mass of needing to employ primary and specialty providers, b) moving non-critical, ambulatory services out of the hospital and into off-site locations and c) how healthcare leaders are mandating that all of their healthcare providers provide service across all clinical delivery locations.

In order to ensure that healthcare organizations can meet the demands of population health management, as well as reap the benefits of attained cost savings and improved patient outcomes, healthcare leaders and organizations have been acquiring physicians and allied health providers at an unprecedented rate. According to a January 9th, 2012 article in Fierce Healthcare, “Hospitals’ physician employment jumped 32 percent from 2000 to roughly 212,000 physicians in 2010, according to the 2012 edition of AHA Hospital Statistics. That means hospitals employ almost 20 percent of all physicians, notes a Hospitals & Health News Daily article.”

Fierce Healthcare continues, “What’s more, the amount of hospitals employing hospitalists rose from 29.6 percent in 2003 to 59.8 percent in 2010.” 1 The impact of this hiring binge has been a negative impact on healthcare organization’s revenue due, in part, to inadequate credentialing software and services skill sets.

Additionally, due to increasing costs as well as a premium on hospital square footage, increasing numbers of healthcare organizations are moving non-critical, ambulatory services out of the hospital setting and into off-site locations. The concept is simple, take non-critical, low revenue generating services out of the hospital and replace them with critical, high revenue generating services. No longer are hospitals being viewed as an “all in one” clinical service provider. Rather, they are being viewed as service delivery experts for only the most complex clinical services. As a corollary, non-critical, low revenue generating services are being moved off-site and directly into the community. The impact of this shift is a) to ensure that providers are managing the health of their population within the community itself and b) the ambulatory centers will serve as a feeder for any in-patient, hospital based services.

As a result of this shift, healthcare leaders are mandating that their employed providers provide services across all off-site locations. For example, providers that previously provided services at only one or two locations are now providing services at multiple locations (both within their employed healthcare organization as well as with competing healthcare organizations).

With this population based and multi-location delivery shift, healthcare leaders are realizing that they need to credential and enroll their providers across all locations. However, in doing so, they are realizing that the credentialing and enrollment process becomes incredibly more complicated. When coupled with the negative revenue impact that not correctly cross credentialing their providers entails, healthcare leaders are realizing that existing credentialing software tools are not equipped to meet these newly emerged, multi-faceted demands.

Credentialing Software – A Brief History

In order to best understand how the credentialing software industry can meet population health based demands, we should first understand the historical evolution of the credentialing software industry. Prior to the advent of credentialing software, most government and managed care provider enrollment applications were filled out manually (e.g., paper and pen). Providers would complete 20-25 applications with an average length of 30-40 pages. Typically, it would take 2-3 hours to complete one application and all data was paper based. In the late 1990s, software companies developed software that reduced the data entry time needed to complete a credentialing application by allowing a physician to enter demographic data into a client server database and “auto-populate” applications from the same database. As a result, physicians only had to enter data one time, but in doing so, could populate all 25 applications at the same time. Whereas it may have previously taken a physician 40 hours to populate and submit all of his/her application(s), it now only took 4 hours.

While tremendously innovative at the time, most credentialing software tools have not evolved past this point. In particular, credentialing software tools have not adapted to the demands of a population health based management in the following ways:

  • They do not offer a cloud based, multi-location, 24/7 web accessibility
  • Because they are client server based, they do not have the programming flexibility to adapt to the changing healthcare environment in a rapid and flexible manner.
  • Enhancements, if any, are rolled out sporadically, and only for those users who are
    willing to pay an enhanced fee.
  • They do not offer easy to understand cross-location operational and financial performance metrics. It is incredibly difficult to understand an organization’s performance from an Institution, Facility/Location, Department/Office, Provider, or Payer perspective.
  • They do not offer flexible, system generated work list and follow up capabilities
  • They do not offer robust analytics that allow the user to conduct data analysis so as to identify operational, financial, or payer bottlenecks
  • They do not offer quality assurance mechanisms
  • They do not offer productivity standard tracking mechanisms
  • They do not incorporate revenue and physician credentialing life cycle metrics into one unified tool
  • They do not offer the ability to link gross charges to their in-process applications
  • They do not offer Key Performance Indicators (KPIs)
  • They do not offer revenue cycle metrics such as: Days In Enrollment (DIE) calculations
  • They do not offer payer performance metrics to keep payers accountable
  • They do not offer a way to link provider credentialing data with provider clinical outcome data

Based on this assessment, it is evident that the existing credentialing software tools have not adapted to the demands of a population management reimbursement and a new approach to credentialing software must be created.

Without tools to meet these growing demands, healthcare organizations will experience an increase in credentialing related denials, frustrated providers, and a loss of critical revenue.

Credentialing Software – A New Approach

In order to meet the demands of a population health management, health leaders must ask their credentialing software vendors for new ways to help them meet their combined cross-location, revenue centric needs. Health leaders would be well positioned if they demanded the following credentialing software functionality:

  • Cloud based, Multi-Location, 24/7 Web Accessibility. Credentialing and revenue data should be available to anyone who has access to the internet and has a user name and password. All data should be stored “in the cloud” and healthcare managers and providers should be able to access their credentialing data and identify where they are in the enrollment process so as to ensure that they are not losing revenue due to delayed credentialing timeframes.
    Another benefit of “being in the cloud” would be a dramatic reduction in upfront capital expenditures. No longer would a healthcare organization need hardware, servers, software, or staff to subsidize their credentialing systems. Rather, all of their software would be hosted by a HIPAA and HITECH approved vendor and the vendor would bear all hosting and data encryption costs.
  • Institution, Facility/Location, Department/Office, Provider, or Payer Operational and Financial Performance Metrics. In this instance, healthcare leaders and managers would be able to instantly identify how their entire institution is performing from an operational and financial perspective. Healthcare leaders and managers would be able to move from a 30,000 foot understanding of their institution’s performance, to a 1 foot understanding of a particular provider’s performance by simply “drilling down” from the highest institutional level down to the provider level. As most successful leaders realize, understanding current performance is the first step in improving and/or maintaining
    organizational and financial performance.
  • Flexible, System Generated Work List and Follow up Capabilities. Healthcare leaders and mangers must require flexible, system generated work lists that their staff can use to meet the growing on-boarding and cross-credentialing demands of their growing organization. Gone are the days of using post-it notes or calendar reminders to conduct credentialing follow up. Rather, credentialing software should drive each step in the credentialing life cycle. Further, by using a system generated work list methodology, healthcare leaders and managers can gain full control over the work of their staff as well as establish accountability metrics.
  • Robust Analytics to Allow the User to Conduct Data Mining and Analysis. Healthcare leaders and managers should require robust analytics to easily identify operational, financial, or payer bottlenecks. Healthcare managers should be able to instantly identify which providers are participating, non-participating, or in process as well as be able to identify the financial impact (positive or negative) of their in-process applications. Additionally, analytics should be easy to use and value-add. Analytics should help identify process breakdowns before they become financial breakdowns. Not the other way around.
  • Quality Assurance Mechanisms and Tools. Healthcare leaders and managers should require the ability to track, trend, and monitor the quality of the credentialing work that their staff is conducting. Currently quality monitoring mechanisms do not exist within the credentialing software industry. Quality monitoring and staff feedback/training should be proactive and on going. It should not be something that exists as an “unknown.”
  • Productivity Standard Tracking Mechanisms and Tools. Healthcare leaders and managers should also require the ability to establish and track productivity metrics and statistics. What actions is your staff taking on an hourly, daily, or weekly basis? Are these actions geared toward obtaining a PIN faster or are they miss-guided efforts? Is your staff wasting critical time during the day or maximizing their time for the good of your organization? The ability to establish and track individual staff productivity metrics should make the staff more efficient and ensure that you are not losing revenue due to inappropriate staff activities.
  • Combined Revenue Cycle and Credentialing Concepts. Key to meeting the demands of population health management initiatives is to understand the financial impact of your credentialing efforts. Current credentialing software tools do not spend any time connecting revenue cycle and credentialing metrics. However, this puts the healthcare leader at a significant disadvantage because a) he/she does not have the correct revenue cycle and/or credentialing metrics to track in the first place and b) he/she does not know what revenue they are losing because their providers are not correctly cross credentialed, or credentialed at all. Examples include:
    • Linking gross charges to “in-process” applications
    • Establishing payer performance metrics such as Days In Enrollment (DIE) for delegated and non-delegated payers
    • Stratifying credentialing follow-up efforts based on providers with the highest associated gross charges first, and then working on the providers with lower associated gross charges second.
    • Following up on credentialing tasks based on a system generated tickle timeframe as opposed to post-it notes and calendar reminders
    • Provider Performance Metrics. In order to facilitate provider participation, software tools should exist which track provider performance and adherence. How long did it take a provider to sign a credentialing application(s), what was the turn around time of the signature process and what are the gross charges, by payer that were affected by the provider’s quick or delayed turn around? Healthcare leaders and managers can effect more timely provider response times if they have the data show the provider whether they are or are not adhering in a timely manner.
    • Payer Performance Metrics. As with facilitating provider participation, software tools should exist which track payer performance. Healthcare leaders need the data to hold payers accountable for their credentialing processing delays. Particularly the managed care contracting departments housed in both hospitals and academic medical centers. The ability to maximize billable charges rests solely in the skills of the managed care contracting department and they need as much data driven assistance as possible when negotiating managed care contracts for your organization. By collecting payer performance data, and publishing that data in a cloud based environment for all healthcare leaders to view, healthcare organizations should be able to incent and/or negotiate improved payer performance rates and turn around times.
    • Provider Score Card Linking Clinical Outcomes With Provider Credentials. As payers continue to link reimbursement with quality outcomes, credentialing software should be able to connect a provider’s primary source documentation verifications (e.g., background checks, criminal history, sanctions monitoring, quality outcomes report cards, etc.) with their patient outcomes. There is a growing trend to link both primary source documentation verification and continuing education credits with quality outcomes so as to get a more complete reimbursement picture. Forward thinking credentialing software vendors will create the ability to link all three components together as well as provide a value add score card which payers and healthcare leaders can evaluate provider performance.

     

    Results – “So What?”

    The “So What?” is simple – After an assessment of the growing demands of population health management, it is clear that as the industry continues to evolve, forward thinking healthcare leaders should demand more from their credentialing software vendors. Healthcare leaders should conduct a needs assessment of their current credentialing software tools and speak with their credentialing departments to see what additional tools they believe that they need to meet the increasing demands of population health management. Healthcare leaders that do not take the time to do so will run the risk of increased credentialing denials, frustrated providers, and ultimately lost revenue. Those leaders that do take the time will be well positioned to exceed the demands of population health management.

    About the Author

    Scott T. Friesen is the CEO of Newport Credentialing Solutions and has over 12 years of healthcare experience in the hospital and faculty practice setting.

    About Newport Credentialing Solutions

    Newport Credentialing Solutions is the nation’s premier provider of cloud based software and IT enabled services dedicated to the credentialing life cycle. Newport provides cloud based workflow, analytics, and business intelligence credentialing software and IT enabled credentialing services to some of the largest academic medical centers, health systems, and multi-­‐‑ specialty group practices in the United States. Newport helps clients “Take Control” over their credentialing life cycle by streamlining operations, reducing credentialing related denials, and generating more cash for their organization.

    For more information on Newport’s software and service solutions, please contact 516.593.1380 or info@newport.theadleaf.com.

    Download

    Click here to download the PDF.

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