Thought Leadership

New Perspectives To Improve the Credentialing Industry

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 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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