One of our goals for our blog is to demystify credentialing so we are creating a series especially for leaders and business process owners who want to gain a deeper understanding of the NCQA standards and credentialing guidelines but don’t have time to wade through 100 pages of regulations. In this series, we’ll break down what you need to know about credentialing,
CMS vs. NCQA Requirements When it comes to credentialing and compliance, there’s a lot to keep in mind. One of the most fundamental issues is this: what compliance standards are you trying to meet? The answer: it depends! For health plans, there are two major bodies to be familiar with: CMS and NCQA. The credentialing process itself is fairly similar
Lessons From The New Healthcare Economy As trendy a term as “the new healthcare economy” has become, it’s one that carries significant weight. Though innovation in healthcare has been consistently on the rise for years, the last few in particular have seen a dramatic uptick in companies looking to disrupt the space. In the first half of 2018 alone, over
The Era Of Megamergers And Vertical Consolidation Recent healthcare industry headlines have clearly shown that vertical consolidation is a major trend. It’s worth examining what’s happening— and what the implications are for the future of the industry. Vertical Consolidation In The Healthcare Industry In December 2018, Cigna and Express Scripts closed their $67 billion merger, which had been approved by
Payers Face Federal Regulations On Horizontal Consolidations Horizontal consolidation continues to occur, particularly for providers. Federal regulators show signs of wanting to impose greater regulations on attempted horizontal consolidations on the payer side of the industry. How Horizontal Consolidation Is Changing Healthcare One of the prime examples of consolidation is the growing number of acquisitions of physician practices. Between July
With virtual integration, organizations can achieve many of the goals of vertical consolidation at a much lower cost. Many industry leaders believe that consolidating hospitals, physician groups and health plans under unified ownership will result in better and more efficient care. That argument has some merits. However, vertical consolidation is costly. For example, health plans that embark on the vertical
Although it may not be immediately apparent to healthcare consumers, blockchain can benefit their healthcare experience and outcomes. An Integrated Care Experience Medical records are fragmented and decentralized, which means that they are not readily available to the patient or to the patient’s range of providers. A patient’s primary care provider may not be able to obtain records from a
Blockchain If you’ve heard about blockchain (and who hasn’t recently), you’ve probably heard about it in relation to cryptocurrency, the most prominent example being Bitcoin. That’s because blockchain is the underlying technological architecture to Bitcoin and other cryptocurrencies. However, blockchain as a technology has uses that extend beyond cryptocurrency. What is Blockchain? Blockgeeks explains it with this simple analogy: “Picture
Right now, processing insurance claims is an incredibly labor-intensive and error-vulnerable process. Dozens or more people might be involved in manual work related to processing a single claim. That’s because there’s so much disparate information to verify: the patient’s identity, the insurance coverage, the payment agreement between payer and provider, the provider’s billing address, etc. And what’s more, networks and
Have you ever found yourself asking primary source verification (PSV) questions like: “Which verifications need to be checked to ensure a provider is properly credentialed to work at your ambulatory care center or clinic?” If so, this post is for you! After a provider fills out an application, the next step in the credentialing process is verifying the self-reported information
