The evolution of 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 a false claim.

For year's credentialing and enrollment have been overlooked as a key component of a practice management process. Fortunately, with greater awareness of the impact that these functions have on the financial and compliance aspects of a highly thriving practice, events are changing.

A look back

Historically, private practice physicians would submit their medical credentials as part of the payer credentialing and enrollment process during the initial stages of establishing their practice. As new doctors would join the practice, the office administrator would file enrollment applications with all of the practice's associated insurance payers. However, while awaiting enrollment, new physicians often treated patients, and the practices filed claims for the services using the practice owner's name, tax ID, and provider number. Unaware of the pending enrollment circumstances, payers were processing and paying claims. Some hospitals followed the same practice.

As hospitals began to acquire these private practices, there has been greater emphasis on credentialing and enrollment. For example, the ability to marry credentialing processes with medical staff processes has become a priority for many C-Suite executives today.

New hires joining a hospital as part of their faculty group practice must be approved by the medical staff department; this means credentialing (also known as privileging) the physician, as a provider, to work in their facility. The process includes obtaining and validating all of the physician's board certifications, academic background, fellowship, and other career history. Based on the medical credentials, whether a non-physician practitioner (like a physician assistant (PA) or nurse practitioner (NP)) or an MD, medical staff then determine what clinical services that the physician is credentialed to perform. In most cases, all of this happens before a single enrollment applications is submitted to the insurance payers.

Physicians typically enroll in numerous insurance plans. On average, a physician will participate with between 20-25 insurance payers. Depending on the insurance payer, the enrollment processes can take anywhere from 90 – 120 days. In order to implement best practices, most practice administrators 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 certificates to be done 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 prior to the requested effective date. In this instance, having all the paperwork ready and the applications submitted to the insurance payer in advance of becoming privileged with the healthcare institution minimizes any unnecessary delays.

Although the incident-to guidelines are restrictive and are most commonly used to report NPP (PA/NP) services, it may be a potential option for billing a physician's services during the credentialing phase. However, the guidelines are very strict; all requirements of this guideline must be satisfied for it to count.

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 resources and adequate 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.

Managing the seemingly unmanageable

As Scott T. Friesen, the CEO of Newport Credentialing Solutions, stated in his "Re-Defining Physician Credentialing Management Strategies" white paper, "What many of these hospitals have failed to realize is that despite integrating these physician practices into their healthcare organizations, many hospitals do not fully understand the operational and financial implications of setting up robust billing and credentialing systems and many hospitals do not have the expertise, staffing, or capital budgets to execute successfully on their physician alignment strategies. As a result, hospitals are finding an increase in physician related denials, frustrated physicians and most importantly, lost revenue."

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 that hospitals are opting to partner with a credentialing and provider enrollment expert.

Credentialing vendors offer the necessary resources to manage the entire credentialing life cycle. For vendors such as Newport, that have the cloud-based technology and provider enrollment domaine expertise, staff are highly trained and understand what is required to manage the the credentialing life cycle successfully. Time-consuming processes such as verification, proactively monitoring all outstanding applications, and working closely with insurance payers to ensure that the enrollment process moves along as quickly as possible are now the responsibility of the vendor partner. With the right technology, processes, and people in place, healthcare providers can even experience an increase in revenue while maintaining compliance.

It is important to remember that if the vendor partner does not have the right software system to manage the credentialing process, success will be difficult to achieve. Also, cloud-based systems typically offer better user analytics and offer portals that support data entry and retrieval access to various stakeholders in the credentialing lifecycle including Medicare, Medicaid, local and all other commercial entities. Utilizing these systems, your vendor partner will be able closely to track automated claims on hold and work to pursue a resolution.

A successful provider enrollment initiative needs to be proactive, this means continuous follow-up on outstanding applications and claims. When a provider implements a reliable enrollment and credentialing solution and is diligent with follow-up the likelihood of substantially increasing revenue is highly likely.

Pam has over 25 years of healthcare consulting experience spanning academic medical centers, community hospitals, faculty practice plans and large private practices. She has consulting experience in all areas of practice and is a recognized industry expert in the area of coding and compliance.

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

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