How does credentialing impact RCM? 3 questions with Newport Credentialing Solutions CEO Scott Friesen

Scott Friesen, CEO of Lynbrook, N.Y.- based Newport Credentialing Solutions, founded the company in 2009, after spending years in revenue cycle management and finding that provider enrollment with managed care and government insurance plans is becoming increasingly important to RCM.

As reimbursement is shifting from a fee-for-service to a value-based model, and as hospitals are embracing population health management and risk-based-contracts to meet these new payment requirements, there has been a tremendous aggregation of employed providers in the market, Mr. Friesen says. Therefore, hospitals have had to apply increased resources to make sure all of their newly employed providers are enrolled correctly with their insurance payers.

"So within the revenue cycle, it's become incredibly important for hospitals to not only ensure that their providers are enrolled with all of their insurance plans, so they are paid correctly, but now, they also have to be able to track, from an enrollment perspective, where and when their providers performed clinical services based on each risk-based contract they participate with. The bottom line is that if hospitals don't manage their provider's enrollment within these risk-based contracts correctly, they risk not getting paid, or getting paid out-of-network," he added.

Newport offers cloud-based software that clients can license to manage their enrollment themselves, or the company offers outsourced services where clients can have Newport manage the entire credentialing life cycle for them on their organization's behalf.

Mr. Friesen spoke with Becker's Hospital Review about why provider enrollment is important and how Newport addresses it.

Note: Interview has been edited for length and clarity.

Question: What sparked the idea for Newport?

Scott Friesen: When we started seven years ago, there weren't a lot of groups that were focusing on this problem on a national scale. There were a lot of billing companies offering provider enrollment solutions, or a lot of it was done in-house. I was hearing more organizations saying they wish they had a better solution to provider enrollment — A group whose sole specialty was provider enrollment. So, because there wasn't a whole lot of focus on offering provider enrollment solutions as a pure play business, we decided to start Newport.

Q: What makes Newport's solutions effective?

SF: Everything we do is revenue-centric. There are other provider enrollment solutions that exist in the market today, but they don't focus on the revenue part of provider enrollment. We focus 100 percent on the revenue piece. For example, let's say we're given 100 providers to manage on behalf of a hospital. What we'll do is not only say, "We need to collect your demographic information and your primary source documentation and we need to start the enrollment process," but we'll also say, "Give us your credentialing claims and denials and let us stratify the dollars associated with your in-process applications so that we can give top focus on those providers with the highest number of charges associated with your in-process applications." By starting from a revenue-centric approach, we can affect real change within an organization and help hospitals and health systems move their provider enrollment department from a cost center to a revenue generator. We look at provider enrollment as a critical function of the revenue cycle, so we very much apply revenue cycle concepts to our provider enrollment methodology.

Q: What's in the works this year for Newport?

SF: What we're starting to pay more attention to is the shift to value-based reimbursement, and we're looking at the importance of risk-based contracting and how that's going to affect provider enrollment and provider data management. So we're really looking at the revenue side of provider enrollment and how that's shifting. Right now you have a fee-for-service contract with a major payer, and you're paid based on the way you've always been paid. But now more hospitals are entering into risk-based contracts, and within that there is an increased need to track, from a technology standpoint, what locations those providers are providing services in and how those locations fit within those individual risk-based contracts. So we're really looking to the future and saying, while only 10 to 20 percent of most payer mixes right now are risk-based contracts, that's going to change pretty quickly, especially with Medicare looking to move a substantial portion of reimbursement to fee-for-value over the next year or two.

We're looking at it from technology standpoint and from a services standpoint and saying, "How can we help clients better manage and be better prepare for when the fee-for-value payment methodology is in full effect?" So we're spending a lot of time talking to people in the industry, working on solutions at Newport, so when it's not 20 percent of your contracts are risk-based, but 40 percent, 60 percent, or 80 percent, we have the technology in place, the services in place, and are ready to help clients easily handle those needs.

 

 

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