RCM Perspective: Technology’s impact on credentialing and enrollment

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I have worked my entire professional career in the healthcare field and have a wealth of experience in physician practice management, medical billing (central billing office), software applications development, information technology management, including electronic medical records implementation and integration.

Most recently I served as Director of Revenue Cycle Services at AtlantiCare Physician Group (APG), an organization I regard very highly.
As I begin to close out my career, I am now partially retired working as a consultant for APG following a move to the sunshine state, I can't help but look back at how the healthcare industry has changed as a result of advances in technology. One area in particular where I personally have seen the benefits of technology (and an area that I believe is not discussed nearly enough) is the credentialing and provider enrollment space.

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. The most recent example of the impact poorly managed credentialing and enrollment processes can have on an organization was found when I was brought onboard at APG.

APG is a large and growing practice with more than 350 physicians and over 80 different billing areas comprised of primary care, group practices, anesthesia, behavioral health, neurosciences and more. When I began working at APG in 2013, the organization relied on a billing company to handle its credentialing and provider enrollment processes in addition to other billing responsibilities. The billing company handled everything from Medicare enrollment to local governmental payers as well as Medicaid and all commercial carriers. However, their lack of experience in credentialing and enrollment and their reliance on antiquated manual processes (they used spreadsheets) resulted in significant non-payment issues. Inefficient processes coupled with poor internal policies led to lost revenue that equaled millions of dollars a year. I knew immediately it was time for a change.

The issues APG faced were not unique. Throughout the years, I have repeatedly witnessed credentialing and provider enrollment issues associated with relying on manual processes such as spreadsheets rather than using a dynamic, cloud-based platform. For example, it is difficult to ensure that staff are working off of the most current spreadsheet. Even more difficult to manage are 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 quickly. In the case of APG, because information was not integrated between our company and the billing company, my staff and I had to allow the billing company additional time to pull together information.

Having worked with credentialing and enrollment technology in my previous job, I know the benefits that can be achieved by automating these cumbersome processes. Credentialing and enrollment technology allows automated claims on hold to be closely tracked so staff can work to pursue a resolution. Reports can be generated in real-time that show specific process details such as provider enrollment by payer group, practice locations(s), credentialing and provider enrollment status, NPI numbers and more. Information is current at all times. When utilizing a cloud-based technology platform, data is available when needed (regardless of staff location) so that everyone remains up to date on enrollment and application status. With the right technology in place, processes are significantly easier and more streamlined than trying to maintain spreadsheets and loading data onto a shared drive as we did previously.

The way healthcare is structured today, physicians have to be enrolled in a large number of plans to get paid. Managing this process manually, when there is technology available to streamline things, just doesn't make sense. When processes are inefficient and inaccurate there is a very high probability that significant revenue can and will be lost; this was the case at APG when I arrived. However, using advanced technology Medicare registration and Medicare facility registration is much more streamlined and managing the status of the applications is a heck of a lot easier.

Having worked with Newport Credentialing Solutions at another hospital, I was very familiar with their cloud-based technology and services. Based on my recommendation, APG agreed to a one-year trial period during which Newport exceeded APG's high expectations. Now, several years later, Newport continues to provide credentialing and provider enrollment services as well as cloud-based reporting to APG. Processes have vastly improved, revenue has increased, and APG remains very pleased with Newport's staff and services.

To be successful in managing credentialing and provider enrollments, you have to know the industry and know it well. With the right people, processes and technology in place, credentialing and enrollment is much more manageable and lost revenue no longer an issue. So what are you waiting for?

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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