7 steps for streamlining physician credentialing processes

Developing an integrated approach to physician credentialing

As provider organizations increasingly adopt population health management and hire more clinicians, many are not ready to handle the complexities of provider credentialing and enrollment in the new payment models. NextGen Healthcare, which develops applications for use within the healthcare industry, offers seven tips to ease the process.

Make provider enrollment an integral part of the revenue cycle program

Practices are spending so much time preparing for payment reform and population health management that they overlook the importance of quickly enrolling newly hired medical staff with all insurers. To capture every collectable dollar, provider enrollment must be an integral part of the revenue cycle. Enrolling staff with all insurers will take considerable time; some applications for enrollment take two to four hours to complete. Then, new physicians need to enroll in the practice's use of HIPAA transactions.

Eliminate insurance eligibility denials upfront

When a physician joins a practice, he or she must be credentialed to work there. Ensure all credentialing documentation is collected and reported, including primary source documentation and electronic signature. Use a Microsoft Excel spreadsheet or a credentialing software system to track missed documentation to help monitor a provider’s enrollment profile and status. Demographic and primary source documentation should be housed in a central cloud-based repository and available for review as needed.

Avoid credentialing and provider enrollment mishaps

Even when solid administrative processes are in place, unusual things can happen. A provider may miss the deadline to submit information to the designated committee. During peak hiring and busy holiday schedules, department heads lose track of who is coming on board. In these cases, providers may be granted temporary privileges. But enrollments, which take 90 to 120 days, can’t happen until a physician is credentialed. And until a health plan awards the provider an effective date of participation, all claims generated by the provider must be written off or held.

Improve provider enrollment using the cloud

Cloud vendors facilitate the use of enrollment technologies without the cost of installing, implementing and maintaining servers and encryption software, and can easily scale to meet enrollment data and storage requirements.

Enhance credentialing performance with KPIs

Check if your provider enrollment software tracks specific key performance indicators. If not, track them manually or via Microsoft Excel. The key is to establish performance baselines and then improve on those metrics. Tasks that require tracking, trending and reporting include in-process charges, department processing times, provider processing times, days in enrollment, and quality measures such as whether staff document when they spoke with a payer representative.

Begin using best practices as early as possible

The enrollment process should not be delayed; the process should begin well before the physician needs to have privileges. Paperwork should be ready and applications submitted to insurers as the credentialing process goes on. Don’t assume everything is progressing according to plan; track progress and ensure staff members know of any delays. Automated reports offer real-time snapshots of what’s going on what still needs to be accomplished.

Outsource credentialing if it makes sense

Vendors specialize in managing the entire credentialing lifecycle through workflow software and advanced analytics and reporting, with administrators of the healthcare organization controlling the time and costs associated with credentialing. The complete tip sheet from NextGen is available here.