Presentation on theme: "Credentialing – The Complete Cycle"— Presentation transcript:
1 Credentialing – The Complete Cycle Dianne Bryant, CPCS, CPMSM, Medical Staff Coordinator Blount Memorial HospitalMaryville, TennesseeValeigh Osborne, CPCS, Manager, CredentialingBlueCross BlueShield of Tennessee, Inc.Chattanooga, TennesseeSheri Wahl Yendrek, Director, Payor Credentialing and EnrollmentRegional One Health and University of Tennessee Regional One PhysiciansMemphis, Tennessee
2 Understand Key Terms and Definitions ObjectivesUnderstand Key Terms and DefinitionsUnderstand how Hospital Credentialing, Payor Enrollment and Payor Credentialing RelateUnderstand Key Elements for Hospital Membership and PrivilegingUnderstand Key Elements for Payor Enrollment – Provider SideUnderstand Key Elements for a Managed Care Company Credentialing
3 Key Terms and Definitions Credentialing – “umbrella term” used for hospital, medical groups, third party payors to verify provider’s credentials and historyHospital Credentialing – The formal recognition and attestation of current medical professional and/or technical clinical competence to grant medical staff membershipProvider Enrollment – The process of enrolling a provider with an payor so as to receive reimbursement for services performedPIN – Provider Identification Number issued by PayorsPTAN (Provider Transaction Access Number) – Medicare’s provider numberPAR – Provider is enrolled (participating) with and will be paid rates under a contract or agreement with an PayorNON PAR – Provider is NOT enrolled and will NOT be paid contracted/agreed upon reimbursements and will either be paid out of network rates usually lower than agreed upon rates with PAR payors, and/or payment will be expected from patients and in some cases payments are sent to the patientEnrollment Application – the Payor specific application that must be completed, submitted, and approved by the Payor in order to become PARRetroactive Enrollment – some Payor companies will only enroll and reimburse a provider effective with the application received and approved date by the Payor, some will ‘back date’ the enrollment date so services prior to the application submission date could be paid (retroactive enrollment)
4 Key Terms and Definitions (continued) Place of Service – The location where services are providedTIN – Tax Identification Number – the federal tax number that the provider or group is assigned or attached to for reporting incomeRemittance Address – The address where payments will be remitted on behalf of the enrolled provider – can be a lockbox address at the bankSupporting Documentation/Primary Source Documentation – The original credentials and documents required by the Payor company to validate licensure, specialty, experience, identityDelegated Credentialing – The process of reducing the enrollment timeframe by shifting the responsibility of verifying Primary Source Documentation from the Payor Company to the Hospital or to a medical group that meets requirementsCAQH – Counsel for Affordable Quality Healthcare. An online data warehouse which allows for provider enrollments for multiple Payor companies – over 200 payors use thisEFT – Electronic Funds Transfer – during the enrollment process your individual PIN and TIN must be attached to a bank account for reimbursement to be automatically deposited to your account vs. receiving a check in the mailERA – Electronic Remittance Advice – the electronic receipt of your explanation of benefits which can be posted electronically in the billing systemNPI - unique 10-digit identification number issued to health care providers by CMS. It replaced the UPIN as the required identifier, and is used by other payers, including commercial healthcare insurers
5 Primary Reason for Provider Credentialing? PATIENT SAFETY
6 Hospital Credentialing, Membership and Privileging Dianne Bryant
7 What Is Hospital Credentialing What Is Hospital Credentialing? Credentialing makes sure that the healthcare provider is who they say they are, they have been trained to do the privileges they are requesting, and they are physically able and competent to do those privileges.
8 RULES, RULES, & MORE RULES You’re not the boss of me!
9 EVIDENCE BASED EVALUATION Practitioner credentialing based on objective assessment of the practitioner’s medical knowledge and clinical skills, as well as evaluations of the practitioner’s professionalism and active participation as a team member in the care system.
10 Evidence Based Evaluation – How’d You do That? 1. Proof of identity2. Education & training3. Military service4. Professional licensure5. DEA6. Board certification7. Work history
11 Evidence Based Evaluation – How’d You do That? 8. Criminal background check9. Sanctions10. Health status11. NPDB12. Malpractice Insurance13. Professional references
13 Credentialing Enrollment Definition – Credentialing vs. EnrollmentCredentialing EnrollmentThe process for obtaining, reviewing, and verifying the documentation of professional providers for the purpose of granting hospital membership and/or privileges. Such documentation includes:LicensureCertificationsProof of PayorMalpractice historyTraining & Work HistoryHistory of Criminal BehaviorGenerally includes both reviewing the information provided by the provider and verifying that the information is correct and complete (Primary Source Verification).The process by which a a medical group or a provider works with payor groups for participation in a payor network. Requires negotiation of:ContractsFee schedulesEnrollment Action
14 Provider Enrollment is a critical piece of the Revenue Cycle Provider Enrollment and the Revenue CycleProvider Enrollment is a critical piece of the Revenue CycleIf MD is not enrolled correctly, timely, and with all payors, MD will not be paidIf provider is not enrolled correctly or at the time services are rendered, claims will not be accepted by the payor company and will be either denied or paid NON PAR or the patient will receive a bill for the services.
15 Key Requirements for Enrollment Acceptable notification timelineAccurate information re: start date, practice locations, etc.Completed enrollment applicationsTN (or other state-specific) licenseDEA registered site of practiceMed/Mal coverage Board certification or board “eligible” for less than 5 years from completion of highest level of trainingLetter of agreement from in-network provider to cover hospital admissions and/or controlled prescriptions pending such by new providerCouncil for Affordable Quality Healthcare (CAHQ) accessNPI - access to the NPPES for NPI maintenance
16 Key Steps to Provider Enrollment - Initial Initial EnrollmentThe process of becoming enrolled for the first time with an PayorFor each Provider there are many payors that require separate applications and submission procedures – some 20 pages longCAQH – enables multiple payor enrollment under 1 application processHowever requires re-attestation/revalidation of provider information every 90 daysIf validation does not occur the profile will expire and claims may be deniedPrimary payors in Tennessee that need enrollment are:Medicare – Cahaba for GA and TNMedicaid – TN and other contiguous statesTNCAREBCBS – TN; for contiguous states – must be licensed in that stateCigna, Aetna, United Healthcare, TricareAmerigroup TenncareEach Payor has rules for backdating/retroactive payments for services provided prior to enrollment approval
17 Key Steps to Provider Enrollment Retroactive Rules Backdating Enrollment Approval dates by PayorMedicare (Cahaba)will go retroactive (back date) 30 days from application receivedApplication processing time is no less than days and is at peak times 180 daysServices provided prior to enrollment date will be denied as provider not enrolled and are not collectible from patientsRailroad Medicare – will use Medicare’s effective date – Must have a RRM claim to initiate enrollment – takes EXACTLY 60 daysMedicaidTN Medicaid may use the Medicare effective date with an appealGA Medicaid may go 30 days from application date with an appealApplication process is no less than 90 daysTNCARE – TN Medicaid Managed Care OrganizationMust have TN Medicaid Number to enroll with:Blue Care, TNCARE Select, Amerigroup, United Community PlanWill not go retroactiveBCBS, Cigna, Aetna, United - No retroactive
18 Provider Enrollment Timelines - Best and Worst Case Steps to EnrollBest Case TimelineWorst Case TimelineOffer of Employment starts the enrollment processPacket to Provider0 Days1 week +Provider signs Employment ContractPacket Complete1 week4 weeks +Enrollment applications sent to payorsMedicare Par2 months6 months +Commercial ParTN Medicaid1.5 months (post MC #)3 months +Enrollment Complete3.5 months9-12 months +
19 Enrollment Team Delays Key Steps to Provider Enrollment – Reasons for DelaysProvider DelaysToo busyFails to send complete info.Delays in signing documentsWaiting for DEA license, malpractice, hospital privilegeVISA/immigration issuesProvides incomplete CVMD doesn’t explain gaps in work historyName mismatch on TN license and SS cardPROVIDER IS RESPONSIBLECarrier DelaysCarrier restrictions (i.e. non-board certified MDs)We recruit providers not acceptable to certain payors and hospitalsWe provide incorrect info (e.g., real start date) leads to late or incorrect applicationOut-of-State Medicaid EnrollmentEnrollment Team DelaysEvery time a provider needs to add a location of service, the enrollment team must complete an add/change form to the payors. If change is not made timely and accurately, claims will be denied and/or delayed.
20 Problematic Enrollment MedicareNPI required for Medicare enrollmentName must match TN license and SS card. Mismatches must be corrected.Multiple group provider numbers and group NPI numbersMedicaidsBCBS TNWill not retro effective datesDon’t drop claims until Electronic Claims letter received (letter 2)Other Commercial Payors – Will not retro ( day enrollment period)Railroad MedicareMust have generated a RRM claimMust have a Medicare number60 days firm for enrollment
21 Key Steps to Provider Enrollment – Re-Enrollment The process of Re-Enrollment requires that Providers ‘re-enroll’ at certain payor defined timeframes – yearsIf provider does not re-enroll with the payor as required they will terminate enrollment/participation and stop payingRe Attestation is the same as Re-EnrollmentExpirables need to managed – they must be kept currentState LicensureMalpractice Certificate of Insurance (facesheet)DEA LicenseBoard CertificationCAQH – requires validation every 90 days
22 Enrollment StructureProviders and Payors prefer to work with one person in the groupSaves MD and group time & moneyThis process gets the majority of doctors enrolled faster & more accurately, so payors are more likely to accept & pay claims in a timely fashionEnrollment manager must keep up with payor policies & regulations to prevent errors & false starts
23 Credentialing with Managed Care Companies Make sure your practitioner has filled out his/her application with CAQHBegin this process immediately – when you have a new practitionerContact the Managed Care Company and request to be in their networks.Maintain all information with CAQH – instead of contacting the Managed Care Company – CAQH should be the hub for Managed Care information.CAQH – requires validation every 90 days
24 Managed Care CompanyThird Party PayorValeigh Osborne, CPCS
25 Privileging vs. Specialty Designation Credentialing with Managed Care CompaniesDifference between Hospital Credentialing and Managed Care Credentialing is:Privileging vs. Specialty DesignationEnsure members receive quality medical care from qualified practitioners/providersEstablish accountabilityCompliance with regulatory boardsNCQA – National Committee on Quality AssuranceURACState Requirements – Tennessee Department of Commerce and InsuranceMinimize or prevent legal riskAttract the most qualified practitionersConsumers and purchasers assume MCO’s have a practitioner screening and/or selection process
26 Credentialing with Managed Care Companies The credentialing process applies to:Anyone that is listed in our Provider DirectoriesMD’s/DO’sAllied practitionersMid-level practitionersFacilitiesAncillary facilitiesHospitalistExcludes:Hospital Based Practitioners (RAP’s)Anesthesiology, Emergency Medicine, Radiology, Pathology, etc.
27 Credentialing with Managed Care Companies BCBST Utilizes CACTUS® software for CredentialingGeneral items verified:License and DEAEducation and Board CertificationNational Practitioner Data Bank (NPDB)Certificate of Malpractice Insurance (Face Sheet)Hospital privilegesAny item that seems adverse – malpractice, sanctions, etc.All practitioner/provider records are stored on a secure drive with limited access to ensure confidentiality.
28 Credentialing with Managed Care Companies Process of re-verifying information that can change overtime every three (3) years for Practitioners and Providers.Keeping expiring information up to date with CAQH, will ensure that the information is current when it is needed by any Managed Care Company.Information obtained by BCBST such asMember Complaints & Satisfaction;Quality Improvement Activities;Medical Record Reviews/Site Reviews
29 On-Going Monitoring by Managed Care Companies Credentialing with Managed Care CompaniesOn-Going Monitoring by Managed Care CompaniesReview the following MONTHLY:LicenseMedicare/Medicaid SanctionsPerformed Quarterly by Credentialing DepartmentMember Complaint information
30 Credentialing with Managed Care Companies Credentialing Committee consists of BCBST Medical Directors as well as Network practitioners who are bound by confidentiality.Internal PhysiciansExternal PhysiciansProvider Network/Contract ManagementHealth Care Services ManagementCredentialing StaffNon Physician PractitionerLegal DepartmentMeets monthly – DO NOT RUBBER STAMP!!
31 Credentialing with Managed Care Companies Appeals processMultiple level process as set forth in the HealthCare Quality Improvement Act of 1986Letter appealInformal HearingFormal HearingArbitration
32 Credentialing and Enrollment - The Domino Effect…a process of processes Medicare applicationFacility CredentialingPayor applicationsCAQHMedicare approvalMedicaid applicationsNPILicense, Med/Mal, DEA, Cert.Get complete MD infoGetting accepted &Loaded to generate claimsNotification$$$
33 Credentialing and Enrollment - The Domino Effect…a process of processes Medicare applicationFacility CredentialingPayor applicationsCAQHMedicare approvalMedicaid applicationsNPILicense, Med/Mal, DEA, Cert.Get complete MD infoGetting accepted &Loaded to generate claimsNotification$$$
34 Credentialing and Enrollment - The Domino Effect…a process of processes Medicare applicationFacility CredentialingPayor applicationsCAQHMedicare approvalMedicaid applicationsNPILicense, Med/Mal, DEA, Cert.Get complete MD infoGetting accepted &Loaded to generate claimsNotification$$$