Terrifying tales of credentialing and provider enrollment mishaps

In honor of Halloween Newport Credentialing Solutions’ Vice President of Operations, Allyson Schiff, continues her holiday series spotlighting some of the most grotesque credentialing and provider enrollment issues facing hospitals today. As a follow-on to her first article, “Medicare revalidations - a horror story in the making,” this next article focuses on hair-raising credentialing and provider enrollment mishaps. Continue if you dare.

When a provider joins a hospital, they must apply for privileges to work there. This process includesobtaining and validating all of the physician’scredentials including, but not limited to, board certifications, academic background, references, andprevious work history. A committee must then approve the provider (sometimes as many as three or four separate committees) before being granted credentialing privileges. Each hospital has its set times for when these committees meet to ensure a smooth process when providers come on board.

The enrollment processes can take anywhere from 90 – 120 days, depending on the insurance payer. Therefore having all the paperwork ready, and the applications that can be submitted in advance of becoming privileged with the hospital submitted, will minimize any unnecessary delays. With privileges received and provider enrollment processed, it is smooth sailing. Sound like a dream?Unfortunatelythis scenario often is exactly that, a dream.

Let the nightmares begin

Consider these frightening (and costly) realities. Despite processesbeing in place to ensure credentialing success, as many have learned mysterious things can happen along the way. A provider misses the deadline to submit information to the designated committee. During peak hiring and busy holiday seasons, department heads lose track of who is coming on board. When situations such as these occur,a provideris granted temporaryprivilegesor provisional services. These “band aids” let a provider work for several weeks or even monthswhile hospital employees attempt to get the actual committee meeting and other processes in placenecessary to grant credentialing priveledges. However, these stall tactics come at a wicked price because enrollments – which take 90 to 120 days – can not happen until a physician is credentialed. No enrollment means no payment. Eek!

Regardless of when a provider starts working at a hospital or medical group, until the health plan awards the provider an effective date of participation all claims have to be written off or held. Now THAT is scary!

Unfortunately, these dreadful situations happen all of the time. In fact, lost revenue can result in easily hundreds of thousands of dollars in a matter of months for a lower level provider; when dealing with highly specialized physicians such as neurosurgeons or plastic surgeons, lost revenue is significantly higher. The result can be downright bone chilling.

How things should work

To avoid becoming the nextcredentialing and provider enrollment victim (or to minimize the pain), consider the following best practices.While privileges must happen first, this does not mean the provider enrollment process should wait. Enrollment should begin well before the physician is granted privileges, paperwork should be ready and certain applications submitted to insurance payers as the credentialing process is happening. Moreover, remember,providersshould never see patients until credentialedAND enrolled in the hospital’s health plans.

Submitting applications and assuming things are progressing according to plan is never a wise decision. Track processes along the way. If there are delays, staff need to know about them. Are the issues on the provider’s side or with the health plan? Was a signature missed or document not included?To keep things progressing, it is important to monitor where a provider is in the enrollment process each step of the way.

Lastly, because credentialing and provider enrollment delays will happen it is important to put steps in place that will help minimize the pain. The ability to monitor how much revenue is being lost andwhich providers are the biggest offenders will allow staff to prioritize actions. Because manually monitoring this process can be a very time-consumingcomplex endeavor, technology will play a pivotal role. Automated reports that offer a real-time snapshot of what is going on including highest dollar volumes by payer, what action has occurred and when, will ensure processes move along as quickly as possible.

While credentiallingand provider enrollment can be difficult to manage, with best practices in place for hospital based providers, they don’t have to be truly horrifying experiences.

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