1. Integrating Provider Enrollment in your MSO
4/7/2019 2:55 PM
Integrating Provider Enrollment in your MSO
Carrie Bradford, MHA, RHIA, CPMSM, CPCS
Senior Director
Professional Staff Services and Credentialing
Northshore University HealthSystem
Evanston, IL
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

2. Historical Perspective
Once upon a time 12 years ago this was my reality…
Challenges
Staff training
File Quality
Lack of understanding of process by outsiders
Database semi implemented
Paper files from previously merged hospital, scanning capable but not used.

3. Historical Perspective
Challenges
Medical Staff process appended to managed care contracting??? Whoa!
Policies and Procedures – how do I do this?
Managed care contacts – what they taught me
Peers …my office based colleagues
Our regulatory friends…what did I need to consider? (TJC, NCQA, URAC, CMS, IDPH??)

4. Reality of Today Delegation with all major healthplans
1600 providers approximately, depending on contract (important – who is the customer?)
Data repository and design to support process
Cross Trained Staff
Created tools to meet regulatory needs of plans which streamlines audits
Let’s talk about clinical privileges…
Provider Enrollment with government entities

5. Strategy Lots of similarities
Primary Source Verification, Credentials Committee approval…
Leverage you files, data and software functionality
Aren’t we the experts???
Focus on the differences to be successful
Checklists- why?
Site Visits
Quality Measures
Complaint Process/Adjudication

6. Provider Enrollment Basics
4/7/2019 2:55 PM
Provider Enrollment Basics
Traditionally a function of the business office or finance
Completion of forms/processes to enroll providers for payment for services rendered
Best practice: should always be for providers who are your employees or are contracted for. Watch out for stark!
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

7. Provider Enrollment Basics
4/7/2019 2:55 PM
Provider Enrollment Basics
Definitions
Facility and Organization Dependent
Government Plans
Medicare/Medicaid
Contracted Plans
Commercial/Third Party Payors: BCBS, Aetna etc..
Facility Credentialing
What is it?...
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

8. Government Plans - Basics
Medicare 101
Part A – Part B
855-I & 855-R
List of accepted providers – pull the regs!
Specialties vs. Taxonomy
Paper submission vs. Electronic
PECOS (Provider Enrollment Chain and Ownership System

9. Government Plans Basics
Medicare Administrative Contractors (MACS)
National Government Services (IL)
Process Enrollment
Process Claims
Maybe different for DME and Home Health
Determined/Contracted by CMS
Medicare “opt out” lists are on MAC pages for your state

10. Government Plans Medicare Enrollment Process Paper vs. PECOS
Wait…lets not forget about location…location
Medicare provider helpline on your MAC website
Paper vs. PECOS
Leverage your software
Use the correct form, if not sure call the hotline
TAT with MAC
Claims retro back 6 months

11. Government Plans PECOS
The NPPES (National Plan and Provider Enumeration System) NPI login is a providers PECOS Log in
Provider must grant you authority to change record on their behalf. (pecos, npi meaningful use)
Identity and Access System of CMS designates your level of access. This is granted by your organizations Authorized or Designated Official

12. Government Plans Medicaid Enrollment State based process
IMPACT – IL electronic enrollment
IL now ONLY does “Managed Medicaid” – County Care, Illinicare, BCBS, Meridian
Other state programs can be intertwined in this enrollment
TAT varies, IL still reporting via legacy system
Leverage your software where you can

13. Government Plans Revalidation Requirement of the Affordable Care Act
Reduces Fraud/Waste
Cleans up the MAC mess (maybe?)
Once every 5 years…this is really not true in all cases
Consequences for not completing (ordering DME, medications, and of course delayed payment)

14. Contracted Plans Managed Care Contracting
Who – IPA, PHO…
What – providers/large groups
Why – for reimbursement at a GOOD rate
How – thru a contract
Where do we fit in?? NCQA, URAC….and delegation

15. Contracted Plans Managed Care Credentialing
CAQH…Council for Affordable Quality Healthcare
Data repository “Proview”
Plans must give provider a number
Data entry along with certificates
Initial and Recredential – Reattest every 180 days
Duplicative for some

16. Contracted Plans Managed Care Credentialing Delegation
Addendum to your managed care contract – READ IT
Yearly audit…even for those who have NCQA CVO cert
Checklist
Gets your providers in quickly…$$$
Rosters
Information Updates
No secondary database requirements

17. Resources Websites: List of MACS Medicare Managed Care CAQH
Medicare Managed Care
CAQH

18. Questions?
Thank you!