Credentialing, enrollments and delays. Oh my.


This post originally appeared on Pulse.

All healthcare organizations—including group practices, ASCs, IPAs, ACOs, patient-centered medical homes and even telehealth companies—are under tremendous pressure to improve operations and maximize efficiency. Two of the biggest problems for these organizations are enrollment and credentialing. As consolidation trends continue and new business models emerge, provider organizations have the opportunity to change how the traditional enrollment process works and eliminate the painful and expensive enrollment and credentialing bottlenecks.

Enrollment (and credentialing) delays are expensive

Before founding andros, I worked as a consultant, helping companies in a dozen different industries implement software and improve business processes. But rarely have I encountered a process as obviously inefficient as payer enrollment. Here’s how it works in today’s world:

  • You recruit a new physician or practice.
  • You onboard them to your organization.
  • You submit for enrollment with health plans.
  • You wait. For 90 days while the health plan credentials the provider(s).
  • Finally, after 90+ days your new provider(s) can start to see patients and get reimbursed for their services.

There has been a lot of talk about how to solve the obvious bottleneck here. Forms can be filled in faster, you can follow up with health plans 2 or 3 times per week and I’ve seen some very creative strategies like buying chocolates for the enrollment team at the local health plan. But provider groups are more or less captive to the health plan’s processing capabilities. I talk with health plan executives every day. They are experiencing major backlogs in their credentialing and enrollment departments, such that it can take them months to process new applications.

Meanwhile, the provider groups (and, perhaps, the providers themselves) are losing a lot of money and potentially making themselves and their communities vulnerable to unnecessary risk. As a result, the communities the providers serve are in fact underserved because the new doctor hired may only be able to see a limited number of patients or none at all, depending on the practice. Or they might try to bill for reimbursement under another provider’s name (which is not a good practice).

Is there a better solution? Yes, there is. It’s called delegated credentialing.

What is delegated credentialing and how does it work?

Delegated credentialing is when the organization responsible for credentialing—the health plan—delegates that responsibility to another party—a provider organization. The delegation process happens in four stages:

  • Agreement: The delegation agreement specifies the responsibilities of each party.
  • Assessment: The health plan will inspect the provider organization’s credentialing processes and determine if it meets or exceeds the plan’s credentialing process.
  • Rosters: The provider organization will provide monthly or weekly rosters to the health plan with changes of status, address, billing information and any new or terminated providers
  • Survey: The health plan will survey the credentialing process once each year or two-year period (depending on the agreement).

After the phase one and two are complete, the provider organization is responsible for credentialing and the provider group can much more quickly collect the necessary information from the practitioner, verify their credentials and approve them. Once the provider organization completes the credentialing function, all that’s left to do is to update the health plan by sending them an updated roster. When the health plan receives the roster update, the new provider can potentially be considered “Participating” and, therefore, eligible for reimbursement (the details of participation start dates could vary depending on the delegated agreement, details, details).

The benefit is clear: Through delegated credentialing you can eliminate the 90-day bottleneck in the provider enrollment process. As a provider organization, you now have control over the credentialing process, which is the most inefficient part of the enrollment process. Now that 90+ day bottleneck is yours to optimize! That’s the game changer. With the right tools, you can get your credentialing and recredentialing operations streamlined. You can complete the process within 5 to 10 days.

Can your provider group become delegated for credentialing?

It depends on the provider group and the health plan. But most health plans are eager to delegate more of the credentialing work to provider groups because it helps them lower administrative costs. But today most mid-sized provider groups are not taking advantage of this because they don’t have an in-house credentialing process in place. If this is your situation, here’s how you can begin to move towards delegated arrangements:

  • Set up a robust credentialing process that meets NCQA standardsNCQA is the de facto standard for health plan credentialing. If you’re running an NCQA-based credentialing process on all of your providers, you’ll fly through the assessment process. Many health plans will want to see the process in place for 6 months or longer before they will agree to delegate, so you’ll want to start as soon as possible. How to do this: If you don’t have a robust NCQA-level credentialing process in place today, learn how andros can help.
  • Review your health plan contracts and see if you already have a delegated clause that can be exercised.
  • Call the provider relations team at the health plans and start the process of applying for delegated status.

How does this impact your bottom line?

Delegated credentialing impacts the provider group’s bottom line in two meaningful ways:

  • The lag time between hiring a new provider and the participation date shrinks to a few days or weeks (depending on your committee review process and delegated agreement).
  • Claims can often be denied/delayed because health plans don’t recognize a provider practice or service location. This causes unnecessary delays to reimbursement payments. A delegated group that manages its roster well, will eliminate this as a source of claim denials altogether.

A note on roster file management

I frequently speak with provider organizations that are using delegated arrangements to their advantage but are struggling with the ongoing roster file management. As a company, we process hundreds of roster files for our clients each month. One thing is clear: if you’re using MS Access and MS Excel to manage your rosters, you’re going to struggle to keep up and get the data into the right hands consistently.

You should take time to evaluate a provider data management system that will allow you to provide rosters to the right organizations in a consistent and secure way. If you’re just setting up these processes, I encourage you not to try to manage them with spreadsheets and email. Invest in the right solutions and your delegated arrangement will pay dividends every month.

Source: New feed

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