Why Credentialing And Provider Enrollment Matter In The Move To Value-Based Care

By Scott T. Friesen, Chief Executive Officer, Newport Credentialing Solutions

In today’s ever-evolving healthcare environment, many practices are struggling to keep up with rising costs and quality of care demands. With the move from a fee-for-service payment model to a value-based payment model, these demands have significantly increased.

In preparation for population health, the number of new hires is expected to be significant as hospitals look to add providers across many specialty areas to help manage the entire continuum of care. The addition of these providers will have a downstream effect on credentialing and enrollment. Organizations that lack the necessary staff and processes to manage provider enrollment can expect a negative impact to their bottom line.

Maintaining A Healthy Revenue Cycle

Credentialing and enrollment are critical business processes within the hospital, physician, and allied health provider revenue cycle. When not managed properly, they can, and will, negatively impact a healthcare organization’s revenue. Similar to a patient not having valid insurance, when a provider is not properly enrolled in a health plan, his/her encounters will be written off. Given just how many patient encounters a provider has in a given day, week, or month, the financial impact can be significant. In preparation for the anticipated hiring frenzy, it is essential that organizations assess their provider enrollment process if they wish to maintain a healthy revenue cycle.

To ensure every collectible dollar is received, provider enrollment must become an integral part of the revenue cycle. This means having the necessary processes, cloud-based technology, and staffing resources in place. Credentialing and privileging must be reviewed continuously, not periodically. These functions require ongoing, automatic monitoring of licenses, sanctions, and exclusions; they also require robust workflow assessments and solutions to support these processes.

The financial repercussions of not enrolling providers with their payers correctly are huge. For example, it is not uncommon for a single provider to enroll annually with some 30-40 payers. With each payer application requiring different criteria and each application taking 2-4 hours to complete, it is easy to miss things. Furthermore, once enrolled as a participating provider, they then need to enroll in Electronic Funds Transfer (EFT), Electronic Remittance Advice (ERA), Electronic Data Interchange for Claims (EDI), Claims Status Inquiry (CSI), and Eligibility Verification (EV). Automating and streamlining these processes, reduces the enrollment timeline, process costs, and aging receivables.

With the right provider enrollment strategy, it is possible to capture every dollar. However, it requires having tools in place to identify the financial risk in-process provider enrollment applications.

The key steps involved in realizing these gains include:

• Conduct a needs assessment of current credentialing software tools and speak to your credentialing staff to see what additional tools they believe they need to meet the increasing demands of population health management. Healthcare leaders that do not take the time to do so will run the risk of increased credentialing denials, frustrated providers, and ultimately lost revenue.
• Use technology to link a provider(s) gross charges to their in-process applications. This allows a practice to triage their at-risk dollars and focus their enrollment activities on those providers with the greatest number of dollars associated with their in-process applications first. After working their greatest at risk providers, they can then focus on those providers with fewer dollars related to their in-process applications.
• Executive, physician and management engagement is critical — have the right metrics and a way to share them in real-time.

While credentialing and provider enrollment can be difficult to manage, with best practices in place you can prevent credentialing related revenue loss. For larger organizations concerned about managing the anticipated increase in providers themselves, consider enlisting the assistance of an outside provider enrollment partner.

About The Author

Scott T. Friesen is Chief Executive Officer of Newport Credentialing Solutions, a provider of cloud-based software and IT-enabled services dedicated to the credentialing life cycle.