The ghost of enrollments future

Last week, Newport Credentialing Solution’s Vice President of Operations, Allyson Schiff, shared with you the first of two holiday themed articles reminiscent of the holiday classic, A Christmas Carol. In her first article, The Ghost of Enrollments Past, Allyson took a look at some of the biggest and most common enrollment mistakes witnessed in 2015. In this second article, The Ghost of Enrollments Future, Allyson offers advice on how to avoid enrollment errors and provides tips for creating a more efficient and effective enrollment process in the new year.

A look ahead at 2016

As discussed in the last article, Medicare and Medicaid revalidations and CAQH were problematic for many healthcare organizations in 2015. Poorly managed processes resulted in deadlines being missed, providers being terminated from plans, and physician’s accounts being frozen. Non-payment issues were a major issue as many providers lost revenue due to in-activity. As we look to 2016, it is important to learn from past mistakes. To help avoid the enrollment mistakes of 2015, consider deploying the following provider enrollment methodology.

Document Collection – Ensure all documentation is collected and reported; this includes primary source documentation and/or provider signatures. Utilize a system, either an Excel spreadsheet or ideally a cloud-based credentialing software system, to track missed documentation. This will help monitor a provider’s enrollment profile and status. Demographic and primary source documentation should be housed in a central, cloud-based repository and available for review as needed.

Comprehensive Par/Non-Par Analysis - After all demographic and primary source documentation has been collected and the provider’s profile created, conduct a comprehensive par/non-par analysis. The purpose of this analysis is to ensure that a) all of the PINs and effective dates that a plan and/or provider has are accurate and b) to identify incomplete and/or missing PINs and effective dates.

Creation of CAQH User Name and Password (where applicable) – For providers who do not have an active CAQH user name and password, either have them create a CAQH profile or ask that they be assigned a billing contact (or outsourced enrollment partner) as the primary credentialing contact to assist with the process. For providers who do not have an active NPI user name and password, an NPI profile must be created.

Creation of PECOS User Name and Password (where applicable) - For providers who do not have an active PECOS user name and password, create a PECOS profile. Identify providers who have not updated PECOS and pursue for completion.

Application Preparation – Once initial provider enrollment applications are identified; prepare the applications for submission. This includes creating the signature pages and ensuring that the provider signs and/or dates only the designated areas – highlighting all areas to be signed in advance will help avoid incomplete applications.

Quality Assurance – If a provider application is not 100% correct, it can (and most likely will) be rejected by the plan. Therefore, it is essential to conduct intensive quality assurance on all applications to ensure complete accuracy.

Application Submission – When submitting paper applications for processing, send via UPS certified mail in order to obtain a signed receipt that the plan has received the application. Once the signed receipt is returned via email, the receipt should be documented within the hospital’s credentialing system; include the date the application was sent to the plan and the date that the plan confirmed receipt. To ensure that the plan received the application, conduct follow-up within 5 to 15 days of submission (depending on the insurance provider).

Application Follow-up – Application follow-up should be deemed as important as A/R follow-up. Follow-up should be systematic, pro-active, frequent, documented and conducted via phone, email, and roster-based spreadsheets.

For large healthcare providers, managing enrollment in-house can be a time-consuming and costly endeavor. Without the necessary staffing resources and adequate processes in place, enrollment can quickly become unmanageable which will create revenue issues. For hospitals unable to conduct the necessary steps to ensure enrollment success, partnering with a credentialing and provider enrollment organization is a great option.


© Copyright ASC COMMUNICATIONS 2019. Interested in LINKING to or REPRINTING this content? View our policies by clicking here.


Top 40 Articles from the Past 6 Months