The Ghost of Enrollments Past

To get you in the holiday spirit, Newport Credentialing Solution’s Vice President of Operations, Allyson Schiff, has recreated the holiday classic A Christmas Carol. In the first of two holiday themed articles, Allyson will focus on the Ghost of Enrollments Past, which takes a look at some of the biggest and most common enrollment mistakes witnessed in 2015. Her second article, The Ghost of Enrollments Future, will offer advice on how to avoid past enrollment errors and provide tips for creating a more efficient and effective enrollment process in the New Year.

A look back at 2015

For many hospitals, provider enrollment issues made for a difficult and costly 2015. Topping the list of issues that have haunted healthcare organizations this past year were Medicare and Medicaid revalidations and CAQH. This article will travel back in time and examine what went wrong, starting first with CAQH’s ProView website update.

CAQH updated its entire process and website on February 24, 2015. In early February, notifications were emailed and faxed to providers across the United States warning of the pending changes and that the website would be down from February 24th through March 2nd. Glitches and bugs led to a nearly month-long delay. Upon completion, providers were responsible for logging in to check that their information was not inadvertently altered.

For providers that regularly read CAQH’s notifications, the process was not an issue. However, because CAQH sends out a significant number of notifications about various items, many overlooked this notice – which also included new password and username requirements - assuming it was just another note. In doing so, these providers put themselves at risk for termination from the health plans; some providers even lost their CAQH numbers.
Providers who realized too late that their existing username and password did meet the new requirements, were locked out of CAQH. If a health plan tried to access the provider’s information for re-credentialing purposes and it was incomplete (because they were unable to or simply weren’t aware they had to log in to verify information), these providers were terminated from plans because of insufficient or inaccurate information.

The lesson learned, too late for some, is to pay attention to ALL email notifications. No matter how many notificationsmay come from a payer, providers must read all of their emailsto ensure that they are fully up to date with payer and CAQH changes.

Revalidations Revisited

March 25, 2015, marked the end of the first revalidation cycle for Medicare across the country. Every provider enrolled with Medicare beforeMarch 25, 2011,was required to submit a revalidation application to Medicare to ensure that their enrollment would remain active. Providers that did not submit a revalidation application would be terminated from Medicare.

While the mandate seems pretty straight forward, the notification process from Medicare to providers created a huge issue. While Medicare sends out multiple notifications by mail alerting providers that revalidations are due, notifications are only sent to the specific location that Medicare has on file. Therefore, if a provider joined a group but was previously participating in other groups, the letters did not make it to the provider (nor did they receive the “Do Not Forward” (DNF) letter stating that their Medicare reassignment had stopped). As a result, deadlines were missed, providers were de-activated from Medicare, and related physician accounts frozen.

Medicare has finished its first round of revalidations. For those providers that were de-activated, they must now re-apply. In doing so he/she will receive a new Medicare ID number and a new effective date; payments maybe lost between the time they were terminated and the time the provider is reactivated.

Similarly, Medicaid revalidations were also an issue for many providers in 2015. Just like with Medicare, the Affordable Care Act requires that each state specific Medicaid program perform revalidations on all providers enrolled prior to March 25, 2011. Because each state has its own set of requirements, additional homework was required. Those that did not follow their state’s specific process were deactivated, which also resulted in non-payment.

Understanding what is required for a state’s particular Medicaid revalidation process beforeenrolling would have helped providers avoid these time consuming and costly mistakes. Stay tuned for the next article in this holiday series, The Ghost of Enrollments Future, to learn how to avoid future mistakes.

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