Credentialing – The Complete Cycle
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Credentialing – The Complete Cycle. Dianne Bryant, CPCS, CPMSM, Medical Staff Coordinator Blount Memorial Hospital Maryville , Tennessee Valeigh Osborne, CPCS, Manager, Credentialing BlueCross BlueShield of Tennessee, Inc . Chattanooga, Tennessee

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Credentialing – The Complete Cycle

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Credentialing the complete cycle

Credentialing – The Complete Cycle

Dianne Bryant, CPCS, CPMSM, Medical Staff Coordinator Blount Memorial Hospital

Maryville, Tennessee

Valeigh Osborne, CPCS, Manager, Credentialing

BlueCross BlueShield of Tennessee, Inc.

Chattanooga, Tennessee

Sheri Wahl Yendrek, Director, Payor Credentialing and Enrollment

Regional One Healthand University of Tennessee Regional One Physicians

Memphis, Tennessee


Credentialing the complete cycle

Objectives

  • Understand Key Terms and Definitions

  • Understand how Hospital Credentialing, Payor Enrollment and Payor Credentialing Relate

  • Understand Key Elements for Hospital Membership and Privileging

  • Understand Key Elements for Payor Enrollment – Provider Side

  • Understand Key Elements for a Managed Care Company Credentialing


Credentialing the complete cycle

Key Terms and Definitions

Credentialing – “umbrella term” used for hospital, medical groups, third party payors to verify provider’s credentials and history

Hospital Credentialing – The formal recognition and attestation of current medical professional and/or technical clinical competence to grant medical staff membership

Provider Enrollment – The process of enrolling a provider with an payor so as to receive reimbursement for services performed

PIN – Provider Identification Number issued by Payors

PTAN(Provider Transaction Access Number) – Medicare’s provider number

PAR – Provider is enrolled (participating) with and will be paid rates under a contract or agreement with an Payor

NON 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 patient

Enrollment Application – the Payor specific application that must be completed, submitted, and approved by the Payor in order to become PAR

Retroactive 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)


Credentialing the complete cycle

Key Terms and Definitions (continued)

Place of Service – The location where services are provided

TIN – Tax Identification Number – the federal tax number that the provider or group is assigned or attached to for reporting income

Remittance Address – The address where payments will be remitted on behalf of the enrolled provider – can be a lockbox address at the bank

Supporting Documentation/Primary Source Documentation – The original credentials and documents required by the Payor company to validate licensure, specialty, experience, identity

Delegated 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 requirements

CAQH – Counsel for Affordable Quality Healthcare. An online data warehouse which allows for provider enrollments for multiple Payor companies – over 200 payors use this

EFT – 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 mail

ERA – Electronic Remittance Advice – the electronic receipt of your explanation of benefits which can be posted electronically in the billing system

NPI - 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


Primary reason for provider credentialing

Primary Reason for Provider Credentialing?

PATIENT SAFETY


Credentialing the complete cycle

Hospital Credentialing, Membership and Privileging

Dianne Bryant


Credentialing the complete cycle

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.


Rules rules more rules you re not the boss of me

RULES, RULES, & MORE RULESYou’re not the boss of me!


Credentialing the complete cycle

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.


Credentialing the complete cycle

Evidence Based Evaluation – How’d You do That?

1. Proof of identity

2. Education & training

3. Military service

4. Professional licensure

5. DEA

6. Board certification

7. Work history


Credentialing the complete cycle

Evidence Based Evaluation – How’d You do That?

8. Criminal background check

9. Sanctions

10. Health status

11. NPDB

12. Malpractice Insurance

13. Professional references


Credentialing the complete cycle

Payor Enrollment

Sheri Wahl Yendrek


Credentialing enrollment

CredentialingEnrollment

The process by which a a medical group or a provider works with payor groups for participation in a payor network. Requires negotiation of:

Contracts

Fee schedules

Enrollment Action

Definition – Credentialing vs. Enrollment

  • The process for obtaining, reviewing, and verifying the documentation of professional providers for the purpose of granting hospital membership and/or privileges. Such documentation includes:

    • Licensure

    • Certifications

    • Proof of Payor

    • Malpractice history

    • Training & Work History

    • History of Criminal Behavior

  • Generally includes both reviewing the information provided by the provider and verifying that the information is correct and complete (Primary Source Verification).


Credentialing the complete cycle

Provider Enrollment and the Revenue Cycle

Provider Enrollment is a critical piece of the Revenue Cycle

If MD is not enrolled correctly, timely, and with all payors, MD will not be paid

If 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.


Credentialing the complete cycle

Key Requirements for Enrollment

  • Acceptable notification timeline

  • Accurate information re: start date, practice locations, etc.

  • Completed enrollment applications

  • TN (or other state-specific) license

  • DEA registered site of practice

  • Med/Mal coverage Board certification or board “eligible” for less than 5 years from completion of highest level of training

  • Letter of agreement from in-network provider to cover hospital admissions and/or controlled prescriptions pending such by new provider

  • Council for Affordable Quality Healthcare (CAHQ) access

  • NPI - access to the NPPES for NPI maintenance


Credentialing the complete cycle

Key Steps to Provider Enrollment - Initial

  • Initial Enrollment

    • The process of becoming enrolled for the first time with an Payor

    • For each Provider there are many payors that require separate applications and submission procedures – some 20 pages long

    • CAQH – enables multiple payor enrollment under 1 application process

      • However requires re-attestation/revalidation of provider information every 90 days

      • If validation does not occur the profile will expire and claims may be denied

    • Primary payors in Tennessee that need enrollment are:

      • Medicare – Cahaba for GA and TN

      • Medicaid – TN and other contiguous states

      • TNCARE

      • BCBS – TN; for contiguous states – must be licensed in that state

      • Cigna, Aetna, United Healthcare, Tricare

      • Amerigroup Tenncare

    • Each Payor has rules for backdating/retroactive payments for services provided prior to enrollment approval


Credentialing the complete cycle

Key Steps to Provider Enrollment

Retroactive Rules

  • Backdating Enrollment Approval dates by Payor

    • Medicare (Cahaba)

      • will go retroactive (back date) 30 days from application received

      • Application processing time is no less than 60-90 days and is at peak times 180 days

      • Services provided prior to enrollment date will be denied as provider not enrolled and are not collectible from patients

      • Railroad Medicare – will use Medicare’s effective date – Must have a RRM claim to initiate enrollment – takes EXACTLY 60 days

    • Medicaid

      • TN Medicaid may use the Medicare effective date with an appeal

      • GA Medicaid may go 30 days from application date with an appeal

      • Application process is no less than 90 days

    • TNCARE – TN Medicaid Managed Care Organization

      • Must have TN Medicaid Number to enroll with:

        • Blue Care, TNCARE Select, Amerigroup, United Community Plan

      • Will not go retroactive

      • Application process is no less than 90 days

    • BCBS, Cigna, Aetna, United - No retroactive


Credentialing the complete cycle

Provider Enrollment Timelines - Best and Worst Case


Credentialing the complete cycle

Key Steps to Provider Enrollment – Reasons for Delays

Provider Delays

  • Too busy

  • Fails to send complete info.

  • Delays in signing documents

  • Waiting for DEA license, malpractice, hospital privilege

  • VISA/immigration issues

  • Provides incomplete CV

  • MD doesn’t explain gaps in work history

  • Name mismatch on TN license and SS card

    PROVIDER IS RESPONSIBLE

Carrier Delays

  • Carrier restrictions (i.e. non-board certified MDs)

  • We recruit providers not acceptable to certain payors and hospitals

  • We provide incorrect info (e.g., real start date) leads to late or incorrect application

  • Out-of-State Medicaid Enrollment

Enrollment Team Delays

Every 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.


Credentialing the complete cycle

Problematic Enrollment

  • Medicare

    • NPI required for Medicare enrollment

    • Name must match TN license and SS card. Mismatches must be corrected.

    • Multiple group provider numbers and group NPI numbers

  • Medicaids

  • BCBS TN

    • Will not retro effective dates

    • Don’t drop claims until Electronic Claims letter received (letter 2)

  • Other Commercial Payors – Will not retro (90-120 day enrollment period)

  • Railroad Medicare

    • Must have generated a RRM claim

    • Must have a Medicare number

    • 60 days firm for enrollment


Credentialing the complete cycle

Key Steps to Provider Enrollment – Re-Enrollment

  • The process of Re-Enrollment requires that Providers ‘re-enroll’ at certain payor defined timeframes – 1-2-3-years

    • If provider does not re-enroll with the payor as required they will terminate enrollment/participation and stop paying

  • Re Attestation is the same as Re-Enrollment

    • Expirables need to managed – they must be kept current

      • State Licensure

      • Malpractice Certificate of Insurance (facesheet)

      • DEA License

      • Board Certification

  • CAQH – requires validation every 90 days


Credentialing the complete cycle

Enrollment Structure

  • Providers and Payors prefer to work with one person in the group

    • Saves MD and group time & money

    • This process gets the majority of doctors enrolled faster & more accurately, so payors are more likely to accept & pay claims in a timely fashion

  • Enrollment manager must keep up with payor policies & regulations to prevent errors & false starts


Credentialing the complete cycle

Credentialing with Managed Care Companies

  • Make sure your practitioner has filled out his/her application with CAQH

    • Begin this process immediately – when you have a new practitioner

  • Contact 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


Credentialing the complete cycle

Managed Care Company

Third Party Payor

Valeigh Osborne, CPCS


Credentialing the complete cycle

Credentialing with Managed Care Companies

Difference between Hospital Credentialing and Managed Care Credentialing is:

Privileging vs. Specialty Designation

  • Ensure members receive quality medical care from qualified practitioners/providers

  • Establish accountability

  • Compliance with regulatory boards

    • NCQA – National Committee on Quality Assurance

    • URAC

    • State Requirements – Tennessee Department of Commerce and Insurance

  • Minimize or prevent legal risk

  • Attract the most qualified practitioners

  • Consumers and purchasers assume MCO’s have a practitioner screening and/or selection process


Credentialing the complete cycle

Credentialing with Managed Care Companies

The credentialing process applies to:

  • Anyone that is listed in our Provider Directories

    • MD’s/DO’s

    • Allied practitioners

    • Mid-level practitioners

    • Facilities

    • Ancillary facilities

    • Hospitalist

  • Excludes:

    • Hospital Based Practitioners (RAP’s)

    • Anesthesiology, Emergency Medicine, Radiology, Pathology, etc.


Credentialing the complete cycle

Credentialing with Managed Care Companies

  • BCBST Utilizes CACTUS® software for Credentialing

  • General items verified:

    • License and DEA

    • Education and Board Certification

    • National Practitioner Data Bank (NPDB)

    • Certificate of Malpractice Insurance (Face Sheet)

    • Hospital privileges

    • Any item that seems adverse – malpractice, sanctions, etc.

  • All practitioner/provider records are stored on a secure drive with limited access to ensure confidentiality.


Credentialing the complete cycle

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 as

    • Member Complaints & Satisfaction;

    • Quality Improvement Activities;

    • Medical Record Reviews/Site Reviews


Credentialing the complete cycle

Credentialing with Managed Care Companies

  • On-Going Monitoring by Managed Care Companies

  • Review the following MONTHLY:

    • License

    • Medicare/Medicaid Sanctions

  • Performed Quarterly by Credentialing Department

    • License

    • Medicare/Medicaid Sanctions

    • Member Complaint information


Credentialing the complete cycle

Credentialing with Managed Care Companies

Credentialing Committee consists of BCBST Medical Directors as well as Network practitioners who are bound by confidentiality.

Internal Physicians

  • External Physicians

  • Provider Network/Contract Management

  • Health Care Services Management

  • Credentialing Staff

  • Non Physician Practitioner

  • Legal Department

  • Meets monthly – DO NOT RUBBER STAMP!!


  • Credentialing the complete cycle

    Credentialing with Managed Care Companies

    Appeals process

    Multiple level process as set forth in the HealthCare Quality Improvement Act of 1986

    • Letter appeal

    • Informal Hearing

    • Formal Hearing

    • Arbitration


    Credentialing the complete cycle

    Credentialing and Enrollment - The Domino Effect…a process of processes

    Medicare application

    Facility Credentialing

    Payor applications

    CAQH

    Medicare approval

    Medicaid applications

    NPI

    License, Med/Mal, DEA, Cert.

    Get complete MD info

    Getting accepted &

    Loaded to generate claims

    $$$

    Notification


    Credentialing the complete cycle

    Credentialing and Enrollment - The Domino Effect…a process of processes

    Medicare application

    Facility Credentialing

    Payor applications

    CAQH

    Medicare approval

    Medicaid applications

    NPI

    License, Med/Mal, DEA, Cert.

    Get complete MD info

    Getting accepted &

    Loaded to generate claims

    $$$

    Notification


    Credentialing the complete cycle

    Credentialing and Enrollment - The Domino Effect…a process of processes

    Medicare application

    Facility Credentialing

    Payor applications

    CAQH

    Medicare approval

    Medicaid applications

    NPI

    License, Med/Mal, DEA, Cert.

    Get complete MD info

    Getting accepted &

    Loaded to generate claims

    $$$

    Notification


    Credentialing the complete cycle

    Conclusions

    Questions and Answers


    Credentialing the complete cycle

    • Thank You!


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