dawn anderson session 2 beyond the basics of provider … · 2018. 4. 4. · automation technology...
TRANSCRIPT
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Beyond the Basics of Provider EnrollmentSession 2
Dawn Anderson
OBJECTIVES
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WHY IS ENROLLMENT SO DIFFICULT?
�Approximately 880,000 physicians in the US
�53% of physicians practice in groups with 5 or more providers
�Employing providers in record numbers
�Timelines
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WHY IS ENROLLMENT SO DIFFICULT?
�Volume and complexity
�Lack of automation
�Actively seek solutions to improve efficiency and improve revenue cycle management.
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2017 Provider Enrollment Survey
Verity, A HealthStream Company
Provider Enrollment professionals at hospitals, healthcare organizations and medical group practices
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Major Challenges Revealed
Challenges(Respondents were able to check all that applied.)
2017 Survey 2016 Survey
Volume of forms/enrollment to be completed for each provider 37.5% 53.8%
Trouble collecting information from provider needed for enrollment 34.1% 42.9%
Knowing when changes are made within my organization or by a provider 31.0% 28.4%
Keeping providers’ information up-to-date with the payers 25.7% 47.8%
Number of providers being on-boarded each month 25.2% 26.9%
Trouble obtaining log in and/or logging into PECOS 24.4% 30.2%
Number of employees allocated to Provider Enrollment functions 22.8% 29.8%
Lack of automation/software for Provider Enrollment 22.6% 23.6%
Using the most up-to-date forms for payers 18.9% 32.4%
Knowing the specific payer criteria and what is required 16.8% 36.0%
Waiting for the provider to authorize a surrogate 16.3% 12.0%
Complicated forms 13.1% 25.1%
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Opportunity for ImprovementTop 10 Opportunities for Provider Enrollment Process Improvement
Very Important
Reduce Enrollment Timeframe 81.2%
Improve Provider Satisfaction 65.2%
Implement Process Efficiencies 64.3%
Automation/Simplify – Reduce Cost & Resources
62.2%
Maintain Provider Directory 57.1%
Dashboard Metrics 52.3%
Provider Data Standardization 48.4%
Enterprise Onboarding Operation 47.8%
Delegated Credentialing 42.9%
Integration with PECOS & CAQH 41.3%
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Data Enterprise Solutions Can Create Efficiencies
One fifth of Health Care Organizations have merged credentialing and provider enrollment
operations in the last 24 months.
28 % are unaware of plans, while others are implementing plans in the next one to two years. What is next for your Organization?
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WHY IS ENROLLMENT SO DIFFICULT?
Most organization enroll 100+ providers in 10-29 health plans
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When asked how many health insurance networks or plans that their providers are enrolled in, it was found that the most common response was 10-29 which accounted for 60.9% of
responses.
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WHY FOCUS ON ENROLLMENT?
�Enrollment = Reimbursement
�Reimbursement = Money
�Thus, Enrollment = Money
Timely enrollment is key to reducing write-offs in revenue cycle.
Hospitals, Healthcare Organizations and Medical Groups are actively seeking solutions to improve efficiency and improve their revenue cycle process.
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WHY FOCUS ON ENROLLMENT?
�Days in A/R due to pending provider Enrollment
�Denial of claims/write-offs due to services rendered prior to enrollment
�Writes offs are lost revenue
Turn Around Time (TAT) assumes days from the initial application until provider is participating (par) with payer.
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TIME IS MONEY WHEN ENROLLING PROVIDERS
$6641 in opportunity costs (what a physician could bill)* per day ($1,560,688 divided by 235 = $6641.23)$1500 estimated daily physician cost **
30 new physicians per yearIf you save 1 day in time = $194,7301 day (30 physicians x $6641)= $199,230 – 1 Day x ($1500 x 30 physicians) = $45,000If you save 15 day on your TAT= $2,920,950
TATs can be shortened with implementation of the best practice recommendations in this presentation
*Source: 2016 Merritt Hawkins Physician Inpatient/Outpatient Revenue Survey**Source: StaffCare, A Company of AMN Healthcare –based on average locum tenens data/cost
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OTHER FACTORS
�Provider Enrollment OnBoarding Delays
�Onboarding Delays = Lost Revenue
�Provider Enrollment lead time is insufficient
�Provider Delays
�Processing Inefficiencies
�Follow-up with payers is time consuming
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BEST PRACTICES
�Review all information to ensure data match
�Enter all information into your database
�Have a Tracking and Workflow job that kicks off each step of your process automatically and provide alerts
�Use PECOS (Provider Enrollment Chain and Ownership System)
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BEST PRACTICES�Ensure CAQH matches your information and
is accurate. Use CAQH ProView to load your data.
�Use Payer Online Web portals, when available
�Maintain tracking numbers of all electronic form submitted
�When submitted paper forms, maintain a copy of everything you submitted and keep accurate records of method of submission.
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BEST PRACTICES
�Email or fax paper applications to payers, when possible.
�If original signature is required, best practice is to utilize Fed-Ex or U.S. Post Office flat rate or certified mail to track your package.
�Follow up with payer
�Document, Document, Document
�Log in to portals to check status of applications
�Always ask for copies of approvals or denials
�Relationship, Relationship, Relationships
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WHAT ARE THE CHALLENGES?�Each Health Plan/Network has their own
application and requirements
�Health Plans require regular updates when providers information changes
�Identical data doesn’t always meant the same thing to a medical group and a health plan
�It’s not a linear process
�Checklists sometimes fail
�Lack of communication
�Silos
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AUTOMATION TECHNOLOGY
�Integrate with CAQH & PECOS to reduce
processing times and improve efficiencies
�Preferably technology with bi-directional feed
to/from CAQH
�Browser-based portal for providers to access their
own data
�Preformatted Payer forms that auto-populates
�Utilize Payer Web Portals
�Expiration Alerts
�Tracking and workflow tools
�Global Update Tools for mass editing capability
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AUTOMATION TECHNOLOGY
�Form letter and ac hoc report generation
�Track details on all database changes
�Editable data dropdown list with pre-populated lists
�User Defined screens and fields
�Security for powerful and robust control of data access
�Primary Source Verification Tools
�Medicare/Medicaid Opt-Out
�Medicare Revalidation tool
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AUTOMATION TECHNOLOGY
�Social Security Death Master File
�Tools to support Delegated Credentialing including rosters
�Payer Participating Screen to track payer information
�Contract Management
�Fee Schedules
�Automation of emails to provider of expirables
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REPORTING METRICS FOR SUCCESS
�Why is it important?
�What should be measured?
� Application Turn-Around-Time (TAT) from applicant back to Provider Enrollment
� Enrollment Turn-Around-Time (TAT) time from application received by payer to provider participating (Par) with payer
� Claims on Hold due to provider enrollment pending – Total Dollars & by Payers & by Days in A/R
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ON-GOING MAINTENANCE
�Reporting capabilities for tracking expiration dates and Recredentialing due dates
�Maintaining CAQH & PECOS
�Successfully submitting Recredentialing applications timely
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PROVIDERS ARE REQUIRED TO MAINTAIN THEIR CREDENTIALS SUCH
AS:
�State License
�DEA
�Board Certification
�Malpractice Liability Insurance
�ACLS/CPR Certifications, Etc.
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HOW DO YOU TRACK EXPIRING DOCUMENTS?
�Utilize a software or tracking mechanism to ensure expiring documents do not expire
�Credentialing/Provider Enrollment Software (reporting capabilities)
�Excel Spreadsheets (not recommended, but often used)
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HOW DO YOU TRACK EXPIRING DOCUMENTS?
�Best practice: request expired documents at minimum 3 months prior to their expiration date
�Example:
• 1st Request 90 days prior to expiration
• 2nd Request 60 days prior to expiration
• 3rd Request 45 days prior to expiration
• 4th Request 30 days prior to expiration
• 5th Request 15 days prior to expiration
• FINAL Request should be made prior to effective date (If you get to this point it is recommended you send a certified letter or email with tracking to confirm the provider did receive your request)
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HOW DO YOU TRACK EXPIRING DOCUMENTS?
�Send notices via email/fax/mail/text (determine what works best in your organization)
�Involve the provider’s office manager and or credentialing point person to assist with ensuring the expired document is updated timely
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MAINTAINING CAQH
�CAQH is required to be re-attested every 120 days
�180 Days for Illinois Providers
�Any expired documents such as medical license, DEA’s, Malpractice Liability Insurance are required to be updated and maintained in CAQH as well
�Any time a document is updated, you must re-attest CAQH in order for the changes to save
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WHAT IF CAQH IS NOT KEPT CURRENT?�If a provider fails to maintain CAQH, the
following could occur:
�Enrollment Delays
�Termination from a health plan at the time of Recredentialing
�Loss in Revenue for non-par status
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MAINTAINING PECOS & PECOS REVALIDATION
Cycle 2 Revalidation:�Cycle 2 revalidation took effect late 2015�Notice begins 6 months prior to due date�If revalidation date is missed, providers will be
deactivated with a lapse in billing�Resources provided by CMS to ensure providers
are not deactivated�http://go.cms.gov/MedicareRevalidation�PECOS Revalidation Notification Center�CMS Correspondence Letter (Note: If provider
is reassigned to more than one group, the notification letter will only be sent to one location.)
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MAINTAINING PECOS�Reminders:
�Revalidation is due every 3 years for DME providers and 5 years for all other providers
In addition to maintaining PECOS revalidation every 5 years, PECOS also needs to be updated with the following changes to remain compliant with CMS standards:
�Reassignment
�Ownership or authorized official
�Practice location
�Contact person
�Correspondence address, etc.
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RECREDENTIALING �Health plans require Recredentialing every 3
years.
�Provider is typically notified 6 months prior to their expiration date.
�During Recredentialing, the provider will need to submit a new updated application and or ensure CAQH is updated.
�All supporting documents that have since expired since initial Credentialing will need to be submitted again, such as:
�License
�DEA
�Board Certification
�Malpractice Liability Insurance
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RECREDENTIALING
�It is important that all requests are submitted timely prior to the Recredentialing due date.
�If Recredentialing standards are not met, a provider will be terminated from the health plan and or/contract which will cause a lapse in billing.
Questions?