what comes first, credentialing or payor enrollment? · 2. must have a contract before you can...

What comes first,

credentialing or payor

enrollment?

Credentialing vs Payor Enrollment

The medical industry uses the word “credentialing” to describe primary source verifications as well as payor

enrollment. Knowing what credentialing means for you in each circumstance is critical.

What’s the Diff?

CREDENTIALING is Primary Source Verification (PSV):

Credentialing is the process of obtaining, verifying, and assessing the qualifications of a practitioner to provide care or services. This includes education, training, licenses, certifications, malpractice as well as peer references and facility evaluations.

PAYOR ENROLLMENT:

The process for a physician to request participation in an insurance plan as a participating or in-network provider.

Who Does What?

CREDENTIALING:

Hospitals, Surgical Centers, IPA’s, Telemedicine Groups, Insurance companies and other organizations who need to grant privileges before you can perform services in their facility or become a member of the organization.

PAYOR ENROLLMENT:

Commercial Insurance companies, Gov’t Entities: Medicare, Tricare, & Medicaid

You are applying to participate in the insurance network in order to service their members and receive in-network payment/rates. They will also list you as an in-network provider in their directory for their members to locate you easily.

*Once the application is filed to the payor, the payor will perform PSV

WHY, WHY, WHY!?

Credentialing (PSV) has many important functions:

1. THE SAFETY OF YOUR PATIENTS!

2. Keep liabilities low for the organizations you are applying for membership

3. Makes sure the providers are who they say they are

4. Ability to monitor your professional information to ensure you continue to meet the standards of the organization over time

5. Allows the facilities to maintain high integrity which directly reflects on you and your good relationship with them

WHY, WHY, WHY!?

Payor Enrollment:

Benefits for participating providers on an insurance plan:

• Accessibility to patients in your community

• Creates trust with patients; you are approved by their plan

• The directory brings in new patients without advertising

• Collect money faster

How Does Primary Source Verification Work?

Primary Source Verification

Process:

Initial Appointment

• Send out appointment packet

• Once received begin primarysource verifications• Pull online sources per standards

• License/DEA/CDS

• AMA/NPDB

• Board Certification

• NPI

• Federal OIG/State OIG

• EPLS/SAM Search

• Send out verification letters perstandards

• Work history

• Education Verifications

• Affiliations

• Claim History

• Peer References


Process:

• Review file and identify any matters for escalation (Red Flags)

• Prepare packet for committee review

– Application

– Verifications

– Matters for Review

– Checklist

– Approval Document

• Once committee approves

– Send out approval notice

– Set up for monitoring

– Set reminder for next reappointment


Process:

Reappointment

• Establish process to track reappointment dates

• Ensure files are requested in allotted time

• Too early (signatures may expire)

• Too Late (may have to rush verifications)

• Once received begin primary source verifications

• Pull online sources per standards

• Send out verification letters per standards

• Review file and identify any matters for escalation (Red Flags)

• Prepare packet for committee review


Process:

Ongoing Maintenance

– Determine what is monitored (based on standards)

– Establish process for monitoring

• Software

• Spreadsheets

– Typical Monitoring

• License/DEA/CDS

• COI (Malpractice)

• OIG/SAMS

• NPDB

• Board Certificates

• CPR/PALS/ACLS

Providers:

• PSV is only for people, not businesses

• Fill out and submit required forms to the entity when you request privileges or participation in their organization

• Organization verifies all of your professional information including education, work history, requests peer reviews etc.

• Monitoring your license, malpractice and sanctions is possible if accepted into the organization. Not all organizations perform continuous monitoring.

How Does Payor Enrollment Work?

NEW & EXISTING PRACTICES :

New Practices:

• Need to be contracted with the payors

• Providers need to be linked to the new contract once its in place

• Fee schedules are set in the contracting phase

• CPT codes, locations, providers, phone/fax numbers need to be correct in the beginning to avoid errors in billing and in the payor’s directory.

New Practices:

• Collect Group Level Information

– Legal Business Name

– Doing Business as Name

– Articles of Incorporation

– W-9

– Bank letter/voided check

– IRS Letter (CP575 or Letter 147C)

– Facility License

– NPI Type 2

– Authorized Official

– COI

– CLIA

– Anticipated start date

– Billing Person/Company

Existing Practices

Are:

• Already contracted with the payors

• Current providers are already on the plan(s)

• Fee schedules are set according to the original contract and updated according to the language in the contract

• Maintenance for the practice contract is not necessary as it stays in place until it is terminated by the payor or the Practice.

• CPT codes, locations, providers, phone/fax numbers may need to be updated to keep the information current

How Does Payor Enrollment Work?

NEW & EXISTING PROVIDERS :

Terminology:

CONTRACTING:

1. Process to add the practice to the payors system with a fee schedule

2. Must have a contract before you can add/link a credentialed provider to the practice

3. This is the time to review the terms of the contract closely and ensure that it fits your practice’s needs

CREDENTIALING:

1. A process for providers not practices

2. Not all providers need credentialing

3. Re-credentialing required every 3 years

NewProviders and New Practices: How to Prepare

• Apply for your Tax ID Number

• Apply for your Type 2 NPI

• Know the difference between using your social security number and a tax ID number.

• Know how will you set up your organization for tax purposes (PLLC, PA, LLC, etc.)

• Know your start date for employment or the opening of a new clinic

• Establish your physical location

• Open a bank account in your business’s name

• Update CAQH

• Decide which payors you wish to enroll with

NewProviders:

Items Needed To Start

• Complete Standardized Credentialing Application from your state (or CAQH log in)

• Current contact information, email & phone numbers

• Update CV to include work history with month/year

• Copy of state professional license

• Copy of Board Certification Certificate(s)

• Copy of DEA certificate

• Copy of Driver’s License

• NPI number(s) Type 1 and Type 2 (if applicable)

• CAQH provider # and log in information

NewProviders:

Items Needed To Start (Cont’d)

• NPI/PECOS user name and password (they are the same login)

• Copy of malpractice Insurance face sheet

• CLIA certificate (if applicable)

• W-9 (exactly as reported to the IRS)

• List of insurance companies to be credentialed with

• List of CME for the last 2 years

• Voided check or bank letter verifying account

• IRS Letter: IRS CP-575 Notice

Final Review To Begin Payor Enrollment:

1. Have your list of payors ready2. Have both your Type I and Type II NPI number completed3. CAQH should be current4. Secure a location, phone/fax number & bank account with your business name5. Know the opening date of your practice or the start date for your new provider

• Start the payor enrollment process at least 90 days prior to the start date of your clinic or new provider.

• Medicare will not accept applications more than 60 days prior to the opening of your clinic or you can request a future date. This may take 90-120 days to complete credentialing, but they will back date to the date up to 30 days retroactively from the date they receive a completed application.

• Most commercial payors will accept applications any time as long as all of the information is in order, including your start date and location. Exception: UHC will not let you start more than 30 days in advance

6. Know if you will be using a billing company or if you are keeping that process in-house 7. Call the payors to ensure the panels are open (for new practices only)8. Gather all of your group documents and provider documents so your Credentialing Specialist will have

access to the information and can file applications on your behalf.

Payor Enrollment Process:

• Contact payors for process

• Is application and contracting done together or separate

• What forms/documents are required

• Where do you submit

• Request Application

• Complete Application

• CAQH

• Documents

• Obtain Provider Signature/Missing Information

• Disclosure Questions

• Adverse actions

• Submit Application


Follow Up

• Call Every 10-14 days

• Questions to Ask:

• Date received

• TAT (Turn Around Time)

• Provider Identification Number

• Effective Date (Credentialing & Contracting)

• Verify Linked to:

• TIN

• NPI

• Address


Keep Copies

• Application

• Contract

• Approval Letter

Maintain Files

• Build a group/provider file

• Document copies

• Keep Demographics Current

• Track Due Dates

• Medicare Revalidations

• Commercial Payors Recredentialing

ExistingProviders:

Maintenance is Key!

• Commercial payors re-credential every 3 years

• Contact each payor and track your next credentialing cycle date

• Notices are typically sent out 90-120 days ahead of the due date

• Most payors re-credential you automatically by accessing your CAQH file but not all do!

• Contact payor to confirm if you have not heard from them 90 days before the next due date

• Be proactive: keep your address and contact information current with all payors & CAQH

• RESPOND TIMELY or you may lose your in-network status or privileges!

NewProviders: The Little

Things

If you are already credentialed:

1. You may just need to be linked to the tax ID number…not credentialed.

2. If the previous practice is outside the geographical area of your new practice, you will need to be CREDENTIALED not linked.

3. The timeframe to link you will be about 30 days less vs credentialing you. (~60 days). If also contracting a new tax ID number, it could still be a 90-120 day timeframe.

4. Re-credentialing dates correspond with the first time you credentialed with a payor NOT the last time you updated your information.

How Does Medicare DMEEnrollment Work?

Medicare DMEApplications

1. Application is for EACH LOCATION (not each provider)

2. NPI must be obtained for each location before you begin application

3. That location must be open a minimum of 30 hours per week

4. Required Documents: ✓ Provider License

✓ Business Liability

✓ Tax Document

✓ Voided Check/Bank Letter

5. Fee Payment for CY2020 - $595✓ New locations,

✓ Additional Locations,

✓ Revalidations & Reactivations

6. Processing time is ~120 days and there is no retro effective date

A few things to note: • Businesses are contracted • Providers are credentialed• Providers can be linked to multiple tax ID numbers/contracts• Cash services can be protected from insurance contracts by using

a separate tax ID number• Linking a provider is faster than credentialing a provider• Medical Directors do not need to be credentialed (except by a

few carriers)• Providers must have a contract to link to in order to be in-

network• Most EFT & ERA’s are managed through your EHR system, not

during the credentialing process.

Heidi HendersonVP of Credentialing

[email protected]

www.1stCredentialing.com

mailto:[email protected]