13 Steps to Limit Credentialing Mistakes Before They Happen
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TriZetto Provider Solutions, a Cognizant Company, will discuss critical steps needed to ensure a successful credentialing turnaround. TriZetto will share best practices and the common pitfalls to avoid to ensure that providers are able to get up and running faster than ever.
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13 Steps to Limit Credentialing Mistakes Before They Happen
- 1. Kareo + TPS Industry-Leading Partnership Denise Haire, Director of Channel Partner Sales Debra Campos, Channel Partner Sales Overlay Exec © 2019 TriZetto Provider Solutions, a Cognizant Company
- 2. 2 Why TriZetto Provider Solutions 8,000 340,000PROVIDERS 2.7BILLION TRANSACTIONS PER YEAR33,500 ORGANIZATIONS PAYER CONNECTIONS 2 TRUSTEDBY
- 3. Kareo + TPS Performance Overview (July 2019) 33,733 Active Providers 99.01% Electronic Claim Submissions $2,824,355,596 (B) Claim Charges Submitted 3,990,252 (M) Claims Processed 96.14% Payer Acceptance Rate 98.52% TriZetto Acceptance Rate Providers Claims Acceptance Rates © 2019 TriZetto Provider Solutions, a Cognizant Company PARTNERS SINCE 2006
- 4. Infrastructure Modernization – Azure® Migration Set the foundation for future scalability, create capabilities to develop new intelligent EDI products and services Microsoft Azure®: Cloud-based data center aligns data transport security protocols to industry standards while also providing significantly enhanced information security and opportunities for growth Key benefits include: • Increased speed • Consistent, reliable storage capabilities • Higher levels of security © 2019 TriZetto Provider Solutions, a Cognizant Company4
- 5. Credentialing A Continuous Process © 2019 TriZetto Provider Solutions, a Cognizant Company
- 6. Credentialing: The What, Who, and Why © 2019 TriZetto Provider Solutions, a Cognizant Company6 Who WhyWhat
- 7. Credentialing: A Continuous Process 7 © 2019 TriZetto Provider Solutions, a Cognizant Company7
- 8. Provider Setup • New provider signs employment contract with practice • Review credentialing status • Practice gets documents from new provider © 2019 TriZetto Provider Solutions, a Cognizant Company8
- 9. Data Collection and Prioritization • Review payer priority • Compile provider documents • Create provider profiles © 2019 TriZetto Provider Solutions, a Cognizant Company9
- 10. Application Completion and Submission • Complete payer application • Obtain provider Signature • Attach required documents • Submit completed forms to payers © 2019 TriZetto Provider Solutions, a Cognizant Company10
- 11. Payer Follow-up • Follow-up with payers on submitted applications • Submit appeals on denied applications • Create alerts to trigger continuous and timely communication with payers © 2019 TriZetto Provider Solutions, a Cognizant Company11
- 12. Obtain Enrollment • Obtain approval • Document approval and expiration date by payer • Set notification for future follow-up © 2019 TriZetto Provider Solutions, a Cognizant Company12
- 13. 13 © 2019 TriZetto Provider Solutions, a Cognizant Company13 Revenue Loss Retroactive Billing Claims Denials Payer drops Provider Patient Costs Increase Patient Satisfaction Decline Credentialing Complications 800hours annually 85missing information %
- 14. Credentialing Best Practices 1414 © 2019 TriZetto Provider Solutions, a Cognizant Company CREATE A CHECKLIST IMPLEMENT TRACKING SYSTEM TRANSITION SUPPORTING DOCS VERIFY APPLICATION OWN THE PROCESS
- 15. Get It Done Credentialing may take anywhere from 90 to 150 days once the payer receives the documentation. • Start early • Be prepared • Check and double-check © 2019 TriZetto Provider Solutions, a Cognizant Company15
- 16. • Review credentialing status • Submit request for data collection • Provide list of documents required (Credentials, applications etc…) • Review payer priority • Collect provider documents • Create provider profiles • Submit completed forms to payers • Submit attachments • Follow-up with payers on submitted applications • Submit appeals on denied applications • Create alerts to trigger continuous and timely communication with payers • Obtain approval • Document approval and expiration date by payer • Set notification for future follow-up • Complete payer application • Obtain signature • Attach required documents Credentialing: A Continuous Process 16 © 2019 TriZetto Provider Solutions, a Cognizant Company16
- 17. Payer Credentialing | Re-Credentialing | NPI Applications | Demographic Changes Hospital Privilege Applications | CAQH Maintenance | License Applications Services Provided 17 © 2019 TriZetto Provider Solutions, a Cognizant Company17 Service Features On-Shore Account Management Credentialing PortalCredentialing PortalOn-Shore Account Management
- 18. Key Benefits © 2019 TriZetto Provider Solutions, a Cognizant Company18
- 19. Thank You Denise Haire Director, Channel Partner Sales (407) 340-1404 | Denise.Haire@cognizant.com Debra Campos Channel Partner Sales Overlay Exec (619) 597-9024 | Debra.Campos@cognizant.com
Editor's Notes
- As we enhance our digital capabilities through innovation and move towards Intelligent EDI (iEDI), we invested in a cloud migration for our EDI Solutions, providing a leading edge technology capability in the market that allows us to deliver digital at scale. The Azure production migration, completed in March, migrated our GEDI/NHXS platforms and associated data. We believe the benefits of this migration far outweigh the costs, and that our clients will benefit greatly from this transition. Some of the key benefits are: Improved security posture for protection of provider data Ability to sustain services and business more seamlessly in a disaster Automated delivery of Infrastructure resources such as Processors, Memory and Disk Leading Edge technology for innovation Reduction in time for delivery of software from ideation to production usage
- So what is credentialing… What is credentialing? Credentialing is a process performed by health insurance payers to ensure that their providers meet all of the necessary requirements and are qualified to perform provider medical services to it’s members Who gets credentialed? Credentialing is performed in multiple organizations; requirements are specific to each (eg. CVOs, ASCs, hospitals, health plans etc…) Practitioners who have an independent relationship with the organization Physicians, Oral surgeons, Chiropractors, Podiatrists, Behavioral health practitioners Rental network practitioners* Other practitioners in payer’s credentialing scope Why credential? To ensure practitioner has legal authority, and relevant training and experience, to provide quality care There’s legal precedent – payers can be found liable for actions of providers participating in their plans* Practitioners need to follow accreditation and regulatory requirements
- As you can see, Credentialing is a continuous process that includes six stages: Provider setup Data Collection and Prioritization Application Completion Application Submission Payer Follow-up Obtain Enrollment Based on this list, credentialing might seem like something an accomplished DIYer could complete in a few weeks. If only it were that easy… Within these six stages, we've identified thirteen common steps in enrolling a new provider with a payer, which we‘ll take you through now. Please note that the process is generally the same for physician re-credentialing.
- Step 1: New provider signs employment contract with practice Step 2: Practice gets documents from new provider (valid medical license, DEA certificate, education and training records, and board certifications) Step 3: New provider submits documents for Payer review
- Step 4: Documents are reviewed by the Billing Company or Credentialing Specialist or provider vs. payer Step 5: More documents may be requested by the payer Step 6: New provider packet for payer complete
- Step 7: Packet submitted to payer Step 8: Payer reviews packet
- Step 8: Payer reviews packet Step 9: Follow up with payer to ensure receipt of information Step 10: Payer responds Step 11: Payer requests additional documentation Step 12: New provider fulfills request from payer for more information
- Step 13: New provider approved by payer
- While credentialing is fundamental to the ongoing success of the provider’s business, it’s not a core strength. It’s easy to see how the DIY credentialing process can go wrong quickly without careful attention. It’s a time-consuming and tedious process, so each step should be monitored and double checked. Some statistics show that a single physician spends 800 hours annually to manage their credentialing requirements. (if you consider 40 hours per packet and 20-25 packets per physician) – source MGMA Connexion Furthermore, 85% of applications are missing critical information that is required for processing** (**Five Steps to Easy Physician Credentialing, Physicians Practice, July 2014) Practices face many potential issues when credentialing doesn’t go as planned. Here are a few of the main complications that can arise: Revenue loss; Retroactive billing; Claims denied; Payer drops provider; Patient costs increase; and Patient satisfaction decline.
- Getting documents from the provider is one of the most important steps in the process. Gathering copies of licenses, board certifications, diplomas and peer-review documents from the new provider—and verifying the information with independent sources—helps you get the procedure in motion right the first time. Additional best practices include: Have one person own the credentialing process; Create a checklist for requesting documents; Ensure that the correct application is being used; Attach all supporting documents (mentioned earlier); and Implement a tracking system to track when information is sent by the practice, received by the payer and approved. Finally, review the entire application and compare it to the information requested by the payer. This seems like obvious advice, but partial applications are sent to payers frequently. At this point, your portion is complete. Now it’s time to ship the package to the payer for approval.
- In our experience, and other sources report the same, credentialing may take anywhere from 90 to 150 days once the payer receives the documentation. There are generally some issues that push the process far past three months, so to mitigate that we advise to: Start Early – It’s imperative the credentialing process at the practice begins well in advance of the new provider’s first day at work. Practices that wait to start the process likely will take a hit to revenue, patients will need to reschedule and patient satisfaction will plummet. Be Prepared – Physician re-credentialing uses roughly the same process that was used the first time. For re-credentialing, however, it’s necessary to ensure previously collected documents remain accurate or are updated, as appropriate. Check & Double-Check – Many credentialing packets are incomplete when submitted to providers. An unfinished submission restarts the process when it’s nearly finished (see Step 11). “85 percent of applications are missing critical information,” according to a credentialing manager quoted in Physicians Practice.** The missing information is typically basic, but necessary detail about the new physician. (**Five Steps to Easy Physician Credentialing, Physicians Practice, July 2014)
- Remember this slide from earlier? Here is another view of that process and the minutiae that go into proper management of the credentialing process. Getting a late start on the process and incomplete packets can be prevented with a solution designed by credentialing experts, like TPS, who know about and understand the intricacies of gathering the right information from providers for payers. They should be responsible for validating and tracking the information every step of the way, as well as delivering regular status updates. The ongoing follow-up process with the payer is essential to successful, first-time credentialing. At TPS, we offer and end-to-end service… Provider Setup Review credentialing status Submit request for data collection Provide list of documents required (Credentials, applications etc…) Data Collection and Prioritization Review payer priority Collect provider documents Create provider profiles Application Completion Complete payer application Obtain signature Attach required documents Application Submission Submit completed forms to payers Submit attachments Payer Follow-up Follow-up with payers on submitted applications Submit appeals on denied applications Create alerts to trigger continuous and timely communication with payers Obtain Enrollment Obtain approval Document approval and expiration date by payer Set notification for future follow-up
- Being equipped with a knowledgeable team of credentialing experts who are empowered by a robust, intuitive portal -- that can take the work on and get going immediately -- is the best way to stay on top of these situations. We at TPS can provide that with our credentialing services. Services Provided Payer Credentialing (Credentialing with New Payers) Payer Re-Credentialing (Re-Credentialing with Payers) NPI Applications Demographic Changes Hospital Privilege Applications CAQH Maintenance (Council for Affordable Quality Healthcare) License Applications *CLICK* Service Features On-Shore Account Management- An Enrollment Specialist will work with the practice for success, working hand in hand during the process Credentialing Portal- a dynamic, intelligent portal that automates most of the credentialing process Key benefits of our Credentialing portal: Workflow Management – The portal is workflow driven. Wizard guides clients through each step of the process – think of Turbo Tax. We connect with any payer in the U.S. and the portal has features to make form population easy, along with guided instructions to input practice and provider information. It monitors and assigns tasks to providers and staff, adding automation to the notification process Real-Time Status Updates – The portal enables automated, continuous data flow for faster information updates, so the client (or you) can access anytime for real time visibility into packet status. Dashboard for Child Sites -- Organizations have visibility into all child sites with dashboard views -- This one is key for Billing Services! We can act as the backend to your billing service. You have the availability to tell your provider groups that “we now do credentialing.” It‘s value added to you as a billing service that we can execute credentialing. Our portal becomes a resource to aggregate and store all that data, and you have visibility into all that activity for your provider groups.
- Data Repository – Never lose a document again with one location to store and update all of your certifications Security – Feel confident that your data/PI is protected Ongoing Support – On-shore credentialing experts reinforced by around the clock support Automated Alerts – Prevent lags in payment with proactive alerts for expiring credentials Transparency – Continuous payer follow-up with complete insight into all enrollments through child site dashboard Fast Processing – With connection to all U.S. payers, transaction times are reduced to days or weeks Efficiency – Save time by eliminating the need for pen-to-paper signatures with e-signature capabilities User-Friendly Portal – Intuitive features combined with NPPES and Google Location to make form completion easy
- Credentialing, or credentialing done right, takes time, effort and likely more than the single “expert” working in the office. We suggest making your own video: One that depicts how a well-thought-out and detailed credentialing process allows a practice to help patients quickly, reduce administration costs, improve income and allow the organization time to focus on business strategy. If you’d like to find out how TriZetto Provider Solutions can help your organization provide these value added credentialing services, please come speak with either of us after this session or visit our TPS later.