Poorly Managed Provider Enrollment Verification Processes Can Prove Costly

Updated on February 17, 2016

By Patrick Doyle, Vice President, Newport Credentialing Solutions

In the evolving and complex healthcare landscape, providers are relentlessly looking for new ways to improve revenue as they battle rising costs and shrinking reimbursements. With the financial implications of having to write off an encounter well known, it is no surprise significant time and effort is being spent on insurance verification. Practices are going to great lengths to ensure a patient’s insurance is verified well in advance of an encounter. If the patient is not covered, the procedure is not scheduled. 

With so much time and technology used to help providers avoid upfront insurance eligibility denials, it is interesting to note how little (time and technology) is used to avoid upfront provider enrollment denials.  Similar to when a patient does not have valid insurance and the patient’s claim is denied, a patient’s claim will also be denied if the provider is not properly enrolled with the patient’s insurance plan. Considering the number of patient encounters that a provider conducts on a given day (some averages for general practitioners are 3-4 patients per hour), the financial impact of denied claims due to a lack of provider enrollment eligibility checks can be significant. Yet despite the financial impact, provider enrollment verification is rarely discussed or practiced within many healthcare organizations.

The following represents an visual depiction of a high performing point of scheduling verification solution:

Screen Shot 2016-02-17 at 8.18.33 PM

It is time that healthcare organizations treat provider enrollment verification with the same urgency as they do insurance verification. The provider enrollment process should begin at the start of the revenue cycle, during scheduling, and in tandem with insurance verification. Similar to a patient not having insurance, if a provider is not enrolled, the procedure should not be performed.

Making Provider Enrollment Verification Easy

Expecting schedulers to call and verify that a provider is properly enrolled with a specific place of service each time that a patient schedules an appointment is unrealistic. In order to avoid upfront provider enrollment denials, some healthcare organizations use Excel or Word document to track a provider’s enrollment participation. When a patient calls to schedule an appointment with a provider, the scheduler checks the Excel or Word document to see if the provider is participating at that particular place of service. However, while this solution provides enrollment data, it is not a reliable option for tracking provider enrollment status. Often, the Excel or Word documents are not accurate or current, and are too difficult to track for larger organizations that work with hundreds if not thousands of providers. Fortunately, advances in cloud-based technology are making point of scheduling enrollment verification significantly easier to manage and monitor the scheduling process. Utilizing cloud-based technology, organizations can extend access to this technology to schedulers. By ensuring that schedulers have real-time provider enrollment data at their fingertips (whether the provider is participating, not-participating, or is in process of becoming participating at one or many locations), costly and unnecessary claims denials can be avoided.

Multi-tenant, cloud-based applications offer real-time access to enterprise-wide enrollment data for true multi-location enrollment statistics. Provider data including names, background information, and copies of documentation can be securely stored within these systems for instant access by those who need it when they need it. By adding front office staff as access personal, schedulers can quickly view a real-time snapshot of provider enrollment status including the providers participating status with all health plans.

Technology Considerations

When considering options for credentialing and provider enrollment technology, it is important to remember one size does not fit all. Because every healthcare organization is unique, it is important that the vendor you partner with is flexible and offers a customized solution. Look for a vendor that takes the time to understand the workflow of your practice and who will work with you to meet your specific needs.

Beware of legacy credentialing software applications that rely on an outdated technology infrastructure. Even with the best people in place, without the right software system to manage the provider enrollment process effectively, success will be difficult to achieve. Cloud-based systems offer better user analytics and provide “portals” which support data entry and retrieval access to various stakeholders including scheduling staff. Look for a system that is intuitively easy easy-to-use and easy-to-understand.

For mid and larger size healthcare organizations who are considering outsourcing their provider enrollment processes, look for a vendor partner that is highly trained and skilled in credentialing and provider enrollment. The partner you select should have an in-depth knowledge of credentialing and provider enrollment and have long-term, established relationships with payers so that they know whom to call when follow-up is needed.

When selecting a vendor, remember that you are also choosing a partner. Take the time to meet face-to-face with the prospective partner before you make your selection; a quick WebEx demonstration is oftentimes not enough.

With the right processes and cloud-based tools in place, lost revenue due to provider enrollment eligibility issues can be significantly reduced, if not eliminated. Having a cloud-based software system in place that allows schedulers to easily view provider enrollment status as patients are being scheduled is essential to achieving long-term financial success.

About Newport Credentialing Solutions

Newport Credentialing Solutions is the nation’s premier provider of cloud-based software and IT enabled services dedicated to the credentialing life cycle. Newport provides cloud-based workflow and analytics software, and IT enabled credentialing services to some of the largest academic medical centers, health systems, and multi-specialty group practices in the United States.

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