Enrollment Nightmares and Zombie Doctors

While Halloween only comes around once a year, hospitals are constantly faced with truly horrifying provider enrollment and credentialing issues. In honor of Halloween, Newport Credentialing Solutions’ Vice President of Operations, Allyson Schiff, will discuss how hospitals can protect themselves when doctors depart… and rise from the dead. Be forewarned, what you are about to read is not a tale… these dreadful situations can happen at any hospital!

Wicked Paperwork

When a provider leaves a hospital, regardless of whether they resign, quit or get fired, it can take a while for paperwork to reach the credentialing office. Depending on the size of the organization, it may be weeks or even months before credentialing is made aware of a provider’s departure. In the meantime, some scary things may happen which can have a creepy effect on a hospital’s bottom line.

When the credentialing team is unaware of a provider’s departure, any A/R outstanding will remain open as unsuspecting staff await signature pages and other missing information from a doctor who has vanished. These charges can sit open for months and months, and as they do, dollars outstanding will continue to increase. Without timely notification of when a provider leaves, a spooky vision of inflated dollars will appear as these charges, that should be written off, go unnoticed.

Timely paperwork can also make the difference in a departing provider’s disenrollment from a group plan. If the required notification is not submitted to the payer, the provider will not be disenrolled for the group plan. As a result, the provider’s contract may carry over to his/her new practice and he/she may still be able to bill under the previous employer’s negotiated rates. Timely notification to payers is important to ensure disenrollment from a group is completed as soon after the provider leaves as possible.

To avoid ghostly disenrollment mistakes requires more than submitting timely departure notifications. Consistent follow-up with payers is a must because it is not uncommon (for payers) to leave a provider as active simply because it is easier.

When disenrollment is improperly handled, issues will continue to snowball (or, because it’s Halloween, fireball). Records, such as hospital rosters, will be incorrect. Even scarier, there will be a discrepancy between the provider organization and health plan when trying to reconcile a list of active providers when inactive doctors remain listed. Even scarier, when providers are in a directory listing for the payers, patients will see them as practicing during their search for a doctor. If a patient calls to make an appointment with a provider who is no longer with a practice, problems can quickly escalate and the hospital opens itself up to patient complaints or even worse, lost patients.

Zombie Doctors

When providers rise from the dead and come back… this is where the nightmare really begins. Depending on when the provider left, chances are the payer was already notified of his/her departure and the provider was terminated from the health plan. In this case, the enrollment process starts all over again. This means new signature pages, new spreadsheets, copies of credentials, etc. It is the same process a new provider goes through which can take easily a month or longer for the enrollment to occur and revenue to start.

If the provider was never terminated form the health plan, or if there was a significant lag between the departure date and when the payer was notified, additional issues will follow. This is particularly true when the credentialing department attempts to submit something to reactivate the provider; this is a red flag to the payer. The payer will want to know why they were never contacted about the departure, or if they were, why was there such a delay in notification. In the meantime, significant time will be wasted as the credentialing department and the health plan work out what happened. These zombie docs who rise up from the dead only to return can have a disastrous effect on records, not just on the credentialing side but on the group/hospital side that they are rejoining as well as the payer side. The result is a hodge-podge of unnecessary delays and a lot of extra work.

How to stop the nightmares

Fortunately, these ghoulish situations can be minimized, and even avoided. To help your credentialing department regain control over provider departures and the chilling effects that can follow, consider the following.

Request provider reconciliation lists. Provider reconciliation lists show which providers are actually in the system (i.e. employed). With information in-hand it is much easier to stay ahead when a provider leaves, especially when working with an outside credentialing partner. How often these lists are provided to the credentialing team depends on the size of an organization. Monthly is fine for small- to mid-size hospitals. However, larger organizations will need these lists on monthly basis. The credentialing team will need to take the lead to ensure this list is provided regularly.

Leverage technology. In the case of a zombie doc, providers who leave and come back, technology can make the re-enrollment process significantly easier and faster. Payer information, previously entered into the enrollment program, can be easily pulled and resubmitted to providers. This alleviates having to start from scratch to obtain signatures, credentials, etc.

Don’t go it alone. Managing the enrollment process is a very time-consuming and tedious task, especially for larger healthcare organizations with literally hundreds, or even thousands, of providers. Enlisting the help of an expert outsourced credentialing and provider enrollment company will ensure you have the resources in place, both people and cloud-based technology, to make sure nothing is missed along the way.

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