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Are You Conducting Pro-Active Quality Assurance on Your Provider Enrollment Applications?

Adriana Evans, Newport Director of Quality and Operations, discusses the importance of conducting pro-active Quality Assurance on your provider enrollment applications.

Q. What is the importance of establishing a pro-active Quality Assurance program within provider enrollment?

A. Establishing and maintaining a pro-active Quality Assurance program is key to ensuring that your provider enrollment applications will be accepted by the payers on the first submission. The bottom line is that conducting robust Quality Assurance is the difference between your providers being paid by your payers vs. not being paid by your payers.

Q. What is the first step in developing a Quality Assurance Team?

A. First, you have to decide that you want to put a Quality Assurance team in place. This team can be comprised of one staff or a number of staff (depending on the size of your department), but the staff need to be 100% dedicated to ensuring that your organization’s quality exceeds industry standards. Depending on the size of your department, consider starting with one Quality Assurance staff member and growing from there.

Q. What are some of the areas that a Quality Assurance team should focus on when conducting pro- active Quality Assurance?

A. While there are many, we recommend focusing on two main areas:

1. Provider Demographics – Ensure that all of the provider demographics data elements are accurately entered into your credentialing system as well as mapped to your provider enrollment applications (if paper) or delegated rosters (if delegated).

2. Primary Source Documentation – Ensure that you have collected and added all of the requested primary source documentation to your provider enrollment application (if submitted by paper).

Q. How should we conduct our Quality Assurance?

1. Establish a Baseline of Acceptable Quality – Determine a baseline of accuracy. If you have 100 data elements on a paper application, is a 5% error rate acceptable (most likely not, but you get the idea).

2. Establish the frequency upon which you will conduct Quality Assurance. We recommend conducting Quality Assurance daily, but the frequency that you conduct Quality Assurance can be determined based on the availability of your staff.

3. Establish a Quality Assurance Scoring System – A Quality Assurance Scoring system will enable you to quantify an error rate and may serve as a guide toward the frequency in which you conduct your Quality Assurance reviews.

4. Conduct Pro-Active Quality Assurance – While the number of applications to review should be determined by the size of your organization, the following is an example of how you can conduct Quality Assurance.

Quality Assurance should occur in two phases:

a. Initial Quality Assurance Review

b. Subsequent Quality Assurance Reviews

First conduct the initial Quality Assurance Review. This can include the following:

a. Pick 10 provider enrollment applications.

b. Review 100 data elements on each application. If you find that 100 out of 100 of the data elements are entered correctly, move to the next application.

c. If you find 10 or more errors on the application, conduct a full quality assessment on the application. Make sure you document the errors for future reference and re-training.

After you have a baseline of quality from your initial Quality Assurance Review, you can conduct future Quality Assurance reviews based on the scores of the initial Quality Assurance Review. The same process for the Subsequent Quality Assurance Reviews should be conducted as for the Initial Quality Assurance Review.

Q. Is Quality Assurance Feedback Important?

A. Absolutely! Giving feedback to your credentialing staff is key to ensuring that the errors do not occur in the future.

a. Review each application and show the Credentialing Specialist what the error was and how to correct it. Provide specific examples to ensure that the Credentialing Specialist understands what was wrong and how to avoid those errors in the future.

b. Ensure that positive and constructive comments are made regarding each account reviewed to assist with providing feedback and development of the Credentialing Specialist.

Implementing a pro-active Quality Assurance program will ensure that your applications are being processed by the payers on the first submission, will reduce the Days In Enrollment, and ensure that your providers are being paid timely and efficiently.



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Newport Credentialing