Benefits of Outsourcing Provider Credentialing And Enrollment Services

Healthcare facilities address the health needs of people and are supposed to treat the sick under all circumstances.  However, for any organization to remain viable and continue to provide services, it needs to be paid for the services provided – fully and in time.  In order to receive their just dues, organizations have to work with various payers, for example payers like Medicare and Medicaid.  Payer enrollment, till a few years back, was not considered necessary by healthcare professionals as important for building their practice.  Today, however, it is not just necessary, but nearly imperative for clinicians to be enrolled with insurance companies.

With the coming into being of the Affordable Care Act, people who were previously without any health insurance, now have access to healthcare coverage.  This, along with the desire and demand of the majority of patients and their families to utilize their health insurance to pay for healthcare services received rather than paying it out of their own earnings, has made it crucial for healthcare providers to enroll themselves with the payers.

Unfortunately, provider credentialing and enrolling with the payers is becoming more difficult with each passing day.  With most insurance panels getting overloaded due to the spurt in membership applications and a lot of them being selective about enrolling providers, the process of enrolling your facility is becoming more challenging.  Under the circumstances, outsourcing your credentialing and enrollment not only looks as an attractive option but also makes financial sense.

Benefits of Outsourcing Credentialing and Enrollment Services:

• Reduces operating costs which can typically be around 30-40%.
• Eliminates errors which could lead to delays in your enrollment.
• Gives you the advantage of getting experts to do the job.
• Allows your staff to concentrate on billing and collections.
• Gives you more time to concentrate on your patients and building your practice.
• Saves you tons of paperwork and hours of frustration.

Remember, enrollment is necessary to remain monetarily viable, however, your practice was started to treat patients.  That is the core competency of your business and anything else can and should be outsourced to allow you maximum time to do what you do best – help sick people get better.

Difference Between Provider Credentialing and Provider Enrollment

Hiring incompetent healthcare providers or allowing them to remain with your facility can lead to increased liabilities in malpractice suits.  In order to ensure that your facility does not suffer from this, it is important that credentialing and enrollment of your providers is managed properly and kept up to date.  Failure to do so can and will have a negative impact on your revenue cycle.  Add to this, the regulatory requirements under which your facility can be at risk of compliance violations.

To ensure that your provider credentialing and enrollment processes are managed properly, it is important to understand the difference between the two.

Provider Credentialing

Credentialing refers to the process of verifying the proven skills, training and education of healthcare providers.  Verification of the providers credentials are done by contacting the “Primary Source”, which has provided the license, training and education.  The credentialing process is used by healthcare facilities as part of their hiring process and by insurance companies to allow the provider to participate in their network.  Credentialing is also the validation of a provider in a private health plan and the approval to join the network.

Provider Enrollment

Enrollment refers to the process of requesting participation in a health insurance network as a provider.  The process involves requesting participation, completing the credentialing process, submitting supporting documents and signing the contract.  Enrollment is also the validation of a provider in a public health plan and the approval to bill the agency for services rendered.

Importance of Provider Credentialing

Provider credentialing dates back to 1000 BC, and has been an important if not critical part of healthcare services.  The process of credentialing has undergone many changes over the centuries; however, the content of credentialing has remained the same – a verification of the education, training, experience, expertise and willingness to provide medical services by the provider.  It was around 1990, that national organizations started which were dedicated to the credentialing of medical providers.  Around the same time, the National Committee for Quality Assurance (NCQA) set guidelines on the process and method of credentialing medical providers.

These guidelines ensure that healthcare providers have undergone stringent scrutiny with regards to their ability and competence, thus making sure that the patients receive the highest level of healthcare.  For a patient, it is assuring and confidence boosting to know that your healthcare provider’s credentials are certified as through the credentialing process, thus ensuring that you are in good and competent hands.  For the provider, it states that their colleagues are held to the same standards as them.  For the healthcare facility, it shows that they value quality care and place the patient’s well being as a primary goal.

It is very important to remember that in today’s world of health insurance and revenue cycles, improper credentialing can lead to delayed or denied reimbursement for services provided.  Worse, it could lead to serious consequences for all concerned in terms of statutory compliance violations, which can result in monetary damages and criminal charges.

Provider credentialing and enrollment has been overlooked as an important component of healthcare management practices for years.  However, their impact on compliance issues and financial aspects to a practice has ensured that these are now key components to any thriving practice.

MedConverge Provider Enrollment and Credentialing Services can help you reduce your on-hold claim values, streamline and standardize administration processes as well as save time while ensuring compliance.  For further information, please contact: info@MedConverge.com

Top 3 Tips for Medicare Enrollment

Medicare enrollment can be very confusing for those enrolling for the first time.  From being aware of the enrollment period to understanding the type of health coverage required; from finding out the various options available to being knowledgeable of the various scams related to Medicare – all this can cause stress and confusion.  Choosing the right plan requires an individual assessment.  A plan that is right for your spouse or friend may not be the right one for you.  It would be a hassle for most to manage two different plans in the same household, but the potential savings make it worthwhile.

Medicare enrollment is automatic for certain groups; for others, it depends on when they become eligible and under what conditions.  You are automatically enrolled if:

• You are receiving retirement benefits when you turn 65.
• You are receiving disability benefits but are still under 65 years of age.

Enrollment in Medicare Part A is automatic for most people at 65 years of age.  However, you can enroll in Medicare Part A and/or Part B manually during your Initial Enrollment Period (IEP) that begins 3 months before your 65^thbirthday.

Keeping in mind the various options that are available and the confusion that the initial enrollment causes most people, here are some tips to help guide you through the process.

Be aware of your Medicare Open Enrollment Period

It is very important to be aware of when you can first enroll in Medicare – missing the date will incur extra costs and fees.  You are eligible for enrollment from 3 months before to 3 months after your 65^th birthday.  For those already enrolled in Medicare, but wishing to change their plan, it can be done during the general Open Enrollment Period from October 15 to December 07.

Understand the different parts of Medicare

Medicare coverage is split into four parts – A, B, C and D, while the supplement plans are known as Medigap.  It is important that you understand each of these parts and their importance.

• Medicare Part A: This covers costs incurred during an inpatient stay at a hospital and includes room and board, general nursing, and medicines. Remember that this does not cover your doctor’s fees.  Also, long-term care hospitalization or skilled nursing facilities are only covered for a limited time.  While Part A does not attract any monthly fee, there are co-insurance costs and deductibles involved.
• Medicare Part B: Covering durable medical equipment and supplies, this also covers fees charged by the physician for both medically necessary and preventive services. However, remember that this coverage attracts a monthly premium, co-insurance costs and an annual deductible.
• Medicare Part C: Known as Medicare Advantage Plans, these are offered by private entities like Blue Shield, Blue Cross and Humana. Structured in a similar manner as HMO and PPO plans, these offer services like dental, eye, hearing and prescription drug coverage along with covering Part A, B and D of Medicare services.
• Medicare Part D: Getting more specific, this plan offered through private health insurance companies covers the costs of prescription drugs. Different plans offer specific lists of drugs that are covered and thus can be tailored to the drugs that you are currently prescribed and using.
• Medigap: To cover the gaps in Part A and B, this policy is offered by private health insurance companies. However, eligibility for Medigap requires enrollment in Medicare Part A and B.  Medigap offers different plans covering different costs.  Labeled Policy A to Policy N, the most comprehensive of the lot is Medigap F.

Find out your health care needs

It is important that you are aware of your health care needs, considering the different options available through Medicare coverage.  You need to be aware of both your current requirements and your probable near future requirements.  Consult with your physician about what could be required in the near future with regard to your health care.  Once you are aware of your needs, choosing the right plan will not be difficult.

Medicare Revalidation in 5 Steps

As per Section 6401 (a) of the Affordable Care Act, all enrolled providers and suppliers are required to revalidate their Medicare enrollment information under the new enrollment screening criteria.

The Revalidation Process

1. Determine which provider is being requested to revalidate
2. View the information checklist
3. Revalidate using Internet-based PECOS or by completing the appropriate CMS-855 application
4. Check your application status

PECOS is the most efficient way to submit your revalidation information.  Using the Internet-based PECOS allows you not only to review information currently on file, but also update and submit your revalidation.  In order to complete your revalidation process, you will be required to either electronically sign the revalidation application or mail the paper certification statement to your MAC after signing and dating the same.  You can also upload any supporting documentation into PECOS or mail it along with your paper certification statement to your MAC.

CMS has implemented several revalidation processing improvements and norms in an effort to streamline the revalidation process and reduce provider/supplier burden, some of which are listed below.

Established Due DatesDue dates will be on the last day of the month (i.e., June 30, 2016, July 31, 2016, August 30, 2016), by which you must revalidate.  Your next revalidation cycles will generally remain on this due date.

Posted Due Dates on Data.CMS.govAs of March 2016, a listing of all of the currently enrolled providers/suppliers is available at:https://data.cms.gov/revalidation.  While DME supplier information will currently not include due dates and is displayed as a blank field, the rest will display a revalidation due date, if they are due for revalidation.  “TBD” (To Be Determined) will be displayed in the due date field for all other providers/suppliers not up for revalidation.  In order to provide sufficient notice and time for the provider/supplier to comply, CMS will post the revalidation due date up to 6 months in advance for each revalidation due date.

Revalidation Due Date Lookup ToolA revalidation due date lookup tool is now available for users.  Users are also provided with the ability to download the entire data set, which can be downloaded in different formats (i.e., CSV, PDF, XLS, XLSX or XML) from:https://data.cms.gov/revalidation.

CrosswalkOrganizations that the individual provider reassigns benefits to; will also be available as a crosswalk at:https://data.cms.gov/revalidation.

Unsolicited Revalidation SubmissionsRevalidation applications submitted by a provider/supplier more than six months before their due date are defined as unsolicited revalidations.  Please do not submit a revalidation application if a due date does not reflect on the file.

Revalidation Notices sent via email/mail2-3 months prior to your revalidation due date, a revalidation notice will be sent by your Medicare Administrative Contractor (MAC) either by regular mail (at least two of your reported addresses: correspondence, special payments and/or your primary practice address) or email (to email addresses reported on your prior applications) reminding you of your due date for revalidation.

Deactivations Due to Non-Response to Revalidation or Development RequestsYour provider enrollment record may be deactivated if your application is received after the due date, or if you provide additional requested information after the due date.  A new full and complete application will need to be submitted by those providers/suppliers who have been deactivated, in order to re-establish their provider enrollment record and related Medicare billing privileges.  While the provider/supplier will maintain their original PTAN, billing will be interrupted during this period of deactivation resulting in a gap in coverage.

Multitude of EHR Notifications Adding To Physician Burnout

It takes just a jiffy to send an online message – compare that to the days gone by, when paper-based systems made sending messages an onerous task.  That is an improvement in our fast paced world today, or is it?  The ease and speed of instant messages has resulted in people sending and receiving far too many messages which take more time and concentration to read, absorb and act upon.  Does the beep of an incoming message break your concentration from the job at hand?  Do you feel compelled to check the message immediately in case it could be something important?  Are you overwhelmed by the large number of messages that you receive?  Do you find these messages interrupting your concentration while you are performing a critical job?  Now, imagine you are a physician treating a patient – and these messages keep breaking your concentration and taking you away from the job at hand.  Working in a hospital is distracting as it is, with the constant flow of patients, doctors, phone calls, emails and paperwork; add to that another level of communications in the form of EHR inboxes and you have added another source of interruption.

According to a study published in JAMA Internal Medicine, primary care physicians and specialists are getting overwhelmed by the large number of notifications from commercial EHR systems, resulting in alarm fatigue.  Alarm or alert fatigue occurs when the large numbers of notifications received by EHR software becomes overwhelming for the healthcare provider.  The study found that physicians spend on an average 66.8 minutes per day processing notifications from EHR use – not a huge amount of time per se, but, these 66.8 minutes are spread across the day, resulting in constant interruptions and break of concentration for the physicians.  Meaningful use requirements and EHR Incentive Programs have resulted in hospitals installing EHR platforms and healthcare providers using more commercial EHR inboxes.

Notifications coming over the EHR include referral responses, test results, prescription refill requests and messages from other healthcare providers.  Any of these notifications could require an urgent or immediate action; and thus the healthcare provider is compelled to look at it the moment it arrives.  The study investigates the methods used by physicians to sort through these large numbers of EHR based notifications to sift out information that is important for quality care.  The researchers cited a previous study conducted by the Department of Veteran Affairs that found alarm fatigue leading to a larger number of occurrences of overlooked test results and missed information.

Analyzing EHR inboxes of 92 physicians at 3 large practices in Texas, the researchers went through 276,207 notifications received during 125 work days.  According to the research, primary care physicians received a mean of 76.9 notifications per day, out of which 15.5 notifications were related to test results.  Compared to this, specialists received only 29.1 notifications with 10.4 related to test results.  The majority of notifications in both cases were from pharmacies or other physicians.  According to the researchers, “Because a single notification often contains multiple data points (e.g., results of metabolic panels contain 7-14 laboratory values), the actual burden and required cognitive effort required of the physicians is likely greater. Strategies to help filter messages relevant to high-quality care, EHR designs that support team-based care, and staffing models that assist physicians in managing this influx of information are needed.”

Vineet Chopra, in a 2014 JAMA article titled ‘Redesigning Hospital Alarms for Patient Safety’ had written, “The consequence of this well-intentioned generalization is epitomized in the din of chirps, beeps, bells, and gongs that typify hospitals today. It is thus not surprising that concerns regarding safety have emerged, even in populations for whom these protective devices were once considered most valuable.”

However, EHR systems offer healthcare providers with a fast and efficient method of conveying information and data – an aspect that can make a huge difference in critical situations.  A proper automated EHR system can decrease the amount of stress faced by healthcare providers, provided they work out a way to balance their EHR use.  The study concludes that improvements need to be developed to make EHR systems more beneficial for both patients and physicians.

5 Ways to Improve Patient Payments

University of Pittsburgh Medical Center (UPMC) reported $212 million in bad debts for the fiscal year 2014. The numbers are not deniable – the reason for bad debt is higher deductibles. While choosing their medical insurance plan, most people tend to choose the plan with the least annual premium, what they fail to realize is lower premium means higher deductible. Result – Increasing number of bad debts. In such cases, there are a few things that one can do to try and minimize the risk of bad debts.

Insurance Eligibility Check

There are electronic tools available in the market which can help you check the patients’ eligibility within seconds. Prior verification of eligibility will help providers and patients understand what their out of pocket expenses could be.

Prior Information to the Patients

Once checked, talk to the patient about the estimated cost that he/she will have to pay for the treatment. Also, let the patient know that there could be some additional unexpected costs that may or may not occur. Once the patient approves the cost, the treatment can proceed. This also enables the patient to know whether there are any problems with the insurance policy that need to be fixed.

Timely Payment

Convince the patient that his/her end of the payments will need to be made while the service is provided to him/her. Once the patient leaves your premises the probability for bad debt increases, which can be resolved only through a legal process.

Payment Plans

Offering a payment plan will ease the patient’s liability. Request the partial payment from the patient, depending on the estimate that you made earlier looking at his insurance status.

Staff training

Train the front desk staff to be as polite or rigid depending on the demand of the situation. It’s finally they who deal with such issues. Having active and spontaneous people at the front desk will help reduce issues.

Taking external help for resolving patient payment related issues can turn out to be the best way forward. MedConverge offers one of the best help desks and patient web portal. For more details, contact us (800) 898-0709 or  info@medconverge.com

5,500 New ICD-10 Codes from October 2016

The medical billing coding system is about to get larger and tougher – with Centers for Disease Control and Prevention (CDC) and Centers for Medicare and Medicaid Services (CMS) adding 1900 diagnosis codes and 3651 hospital inpatient procedure codes to the ICD-10 coding system for fiscal year 2017.  As it is, there are 68000 billing codes under ICD-10, as compared to 13000 which were under ICD-9.  Although the new codes are supposed to make the system better and more transparent, ease the billing process, assist is population health and reduce costs across the healthcare delivery system; health providers were worried about integration of the new ICD-10 with the existing system.  However, irrespective of their misgivings, health providers prepared themselves for the switch and started implementing the same from October last year.  The AMA and CMS provided resources to assist healthcare providers in figuring out ICD-10 and the transition from ICD-9.

In a meeting on March 9, officials of the CMS announced the addition of 5500 codes to the ICD-10 diagnostic library.  These codes will come into effect from October 01, 2016, exactly a year after the replacement of ICD-9 with ICD-10.  The reason for this large number of new codes is the partial freeze that was in place on updates prior to the original launch on October 1, 2015.  This update will include the backlog of al proposal for changes to the code set.

According to CMS, 97% of the 3651 new hospital inpatient procedure codes will update the cardiovascular and lower joint body systems.  Codes for face transplant, hand transplant and donor organ perfusion are also part of the new codes.  Expected next month, the new and revised ICD-10-CM (Clinical Modification) and ICD-10 PCS (Procedure Coding System) codes will be included in the hospital inpatient prospective payment system proposed rule for fiscal 2017.  Diagnostic Related Group changes will also launch on October 1, 2016.  CMS has intimated that written comments on the codes will be accepted until April 8, 2016.

The new procedure coding system codes are available on the CMS website.