There is a fast-moving push by Medical Staff Professional speakers, consultants, and educators to align Medical Staff Credentialing, Provider Enrollment, and Delegation within an organization. This is largely in response to the cry for help from healthcare organizations who have recognized the impact that non-existent or poorly timed government and commercial provider payer enrollment can have on their revenue cycle. While it is positive that the importance of these tasks are getting their due time, payer enrollment is a critical business process that should not be a back-office function that lacks strategic importance.
Just as when a patient does not have valid healthcare insurance to pay their bill, when a provider is not properly enrolled in a health plan, his or her encounters will be written off. The financial impact can be noteworthy given how many encounters a provider has in any given day, week or month. A strategic, focused, and continuously monitored payer enrollment strategy can allow an organization to capture every dollar.
The ‘look’ to the keepers of a provider’s credentialing file is a natural one. Medical Staff Professionals are the first point of contact with a newly hired or billable medical provider within an organization. They are the authority on capturing a complete professional credentialing file in order to process an application for privileges and grant access to their patients. They can manage data, expiring credentials, clinical competency, peer review, and the delineation of privileges with a high attention to detail. They understand accreditation standards and can translate those standards to a payer scenario.
They are not, however, revenue cycle experts. Being highly skilled in managing provider data is not enough when faced with the task of enrolling providers in contracted healthcare plans. Provider payer enrollment is a reflection of how an organization bills for patient services. It is, therefore, critical that those charged with completing payer enrollment applications are well-versed in the organization’s billing practices.
To be sure that every dollar is collected upon, provider enrollment must be a fundamental part of the revenue cycle. And the keepers of the process should have a hybrid-skill set that includes both Medical Staff Professional expertise and Patient Billing Professional expertise.
Seemingly straight-forward questions on payer enrollment applications have deeper meaning to the payers themselves. Provider-types, location-types, business structure, taxonomy codes and more are key to the successful participation with government and commercial plans. They are also critical to ensuring an organization’s compliance with the State and Federal rules and regulations that an organization’s Revenue Cycle Department must adhere to.
Provider credentialing and privileging should be reviewed continuously. A comprehensive and routine workflow should be in place for the ongoing monitoring of licenses, sanctions, and exclusions. Those charged with payer enrollment tasks should have a high-level knowledge of provider types, such as Medicare Part A, Part B, Hospital-based vs Clinical-based, Primary Care vs. Specialty, professional fees vs. facility fees, and emergent vs. non-emergent to name a few. Medical Staff Professionals often lack this specialized knowledge.
Healthcare leaders that do not take the time to enlist the right staff in the payer enrollment process will run the risk of frustrated patients, credentialing and claims denials, and ultimately a loss on their group’s financial bottom line. These highly detailed processes can be difficult and time-consuming for a group to manage on their own, especially for growing organizations going through an increase in providers. An outside provider enrollment partner may be the best choice to manage these needs and mitigate revenue loss.
The first step in formulating a strategic plan to handle the Payer Enrollment function in your organization is to quantify the potential opportunity inherent in your organization today. Encompass has a free tool that enables healthcare professionals to take that first step.