Thought Leadership

New Perspectives To Improve the Credentialing Industry

Q&A: The Benefits of Implementing Provider Enrollment Metrics

Patrick Doyle, Newport VP of Business Development, shares the benefits of implementing provider enrollment metrics for your Provider Enrollment Department.

Q. What are some of the common areas where high-performing hospitals and health system can improve?

A. One area where hospitals and health systems can improve is by focusing on their Provider Enrollment Departments. Hospitals and health systems are spending so much of their time preparing for payment reform and population health management, that they often overlook the importance of their Provider Enrollment Departments and how those departments will help them execute their population health management strategies.

Q. What are some particular areas that that providers and administrators can focus on?

A. Provider Enrollment Metrics. Despite being a critical part of any revenue cycle, there are very few industry wide metrics that are followed.

Q. What is the impact of not following the right provider enrollment metrics?

A. Lost revenue. If your providers are not fully enrolled with all of their locations and payers, and you do not have the metrics to track their enrollments, your providers will not be paid correctly and you won’t know it.

Q. What are some examples of provider enrollment metrics that can be used?

A. One example would be understanding your “Participating,” “Non-Participating,” “In-Process,” and “Total Opportunity?” In order to best understand these metrics, you have to understand how many providers, payers, and locations that you want your providers to participate with. The goal is to be as close to 100% as possible.

In order to calculate your “Par Percentage,” you can use the following formula: Total Providers * Total Number of Locations * Total Number of Payers. Therefore, if you have 10 providers, and 10 locations, and 10 plans, your total “Participating Opportunity” is 1,000. If you are only 80% “Participating” that means you are “Not Participating” in 20% of your plans or locations. Your Non-Participating status means that your claims are being denied and you are risking lost revenue.

Another metric to track is your Days In Enrollment (DIE) for your delegated and non-delegated payers. The DIE tracks your department and your payer’s performance. The formula for calculating DIE is: Total number of elapsed days from the time your submit a paper application to a payer, compared to a standard turn around time (e.g., 90 days). If the total number of elapsed days is 120, you know the payer is not performing well. If the total number of elapsed days is 45, you know the payer is performing better than the average.

Q. What are the steps involved in developing these provider enrollment metrics?

A. Understand that provider enrollment is no different than other aspects of your revenue cycle. A helpful step is for hospitals and health systems to identify those credentialing metrics that are important to your organization and revenue, and implement the correct tools and benchmarks you want to measure your performance against. Another step is to compare your performance to your industry peers.



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