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Supero Healthcare Solutions Provider Enrollment and Credentialing Blog

3 Common Provider Enrollment Mistakes to Avoid

Posted by Brian Agnew on Fri, Dec 07, 2012 @ 16:12 PM

describe the imageProvider enrollment is an inevitable process that comes with running a healthcare business such as a physician practice, rehab clinic, or urgent care center. Becoming a provider with commercial and government insurance companies is essential to maintaining steady patient referrals and cash flow and are the backbone of any successful practice. Avoiding the following common mistakes will ensure your credentialing application and provider enrollment process moves along efficiently and timely.

 

1. Forgetting to Include Complete Information

During this early application phase, an insurance company needs a thorough picture of your current and past medical practice to determine if you would be a good fit for their provider network. Requested data usually includes practice address, phone, fax, contact information, services provided, copies of your licensure, employment history, average patient profile and any records of past legal troubles regarding your medical practice. Omitting any of this data can lead to delays in your provider credentialing, and it can sometimes be grounds for a denial. Also forgetting to sign the applications and contracts can cause significant delays.

Whether you are compiling this data yourself or working with a provider enrollment and credentialing company, checking your initial application for completeness is essential. Using a provider enrollment and credentialing service will ensure that your information is complete and in the correct format and uncover any areas you may have forgoten about.

2. Starting Too Late

Many practices get started on the provider enrollment process too late, which can be a matter of success and failure for a new start-up practice.  In ideal situations, you would want to begin the process at least 90 days prior to opening (with the exception of a provider already joining an existing practice).  It should be known that for a new start-up, outsourcing the work to a provider enrollment company, can take at least 4 - 6 months to complete the entire process, doing it on your own could take 8 - 12 months.  Many practices simply cannot survive within that time frame.  

3. Lack of Follow-Up

As mentioned above, the average provider credentialing process can take months for many practices. Regular contact with the insurer will keep you up to date on your application's status. It can also help to shorten this waiting period in some instances.  Many payors are understaffed and the process takes much longer than in the past and being proactive is your best weapon. 

Enrolling as a medical provider requires attention to detail and consistent follow-up with an insurer. Working with a provider enrollment and credentialing company can help you complete each phase without unnecessary delays. They can provide you assistance with both government-based and private insurer applications as well as any CAQH and NPI requirements.

 

If you are seeking assistance with Commercial Insurance or Medicare Provider Enrollment.  Please click here for more infomation. 

Brian Agnew is President of Supero Healthcare Solutions a leading practice management company focused on provider enrollment and credentialing services for physicians and other healthcare providers.

 

Topics: Provider Enrollment, Payor Credentialing, Provider Enrollment Services, Physician Credentialing, Medical Credentialing, Provider Credentialing, Insurance Credentialing, Medicare Provider Enrollment, Credentialing

Provider Enrollment - 2013 Medicare Physician Fee Schedule Issued

Posted by Brian Agnew on Tue, Nov 27, 2012 @ 19:11 PM

Provider Enrollment News From Supero Healthcare Solutions:


CMS

The CY 2013 PFS final rule with comment period was placed on display at the Federal Register on November 1, 2012. The conversion factor dropped from $34.0376 in 2012 to $25.0008. Add this to the changes in the RVU values themselves and we could have a real mess on our hands. Physicians are on edge to see what might happen to them with regards to their reimbursement via our beloved government sponsored program: Medicare. 

Some of the winners of the new fee schedule include family medicine doctors who , with changes in care coordination payment and some other changes in the rule, stand to see a 7% increase and other primary care providers will see a 3% - 5% increase.  However, this will only happen if Congress averts the statutorily required reduction in Medicare’s physician fee schedule.  A list of how each specialty is impacted is listed by the AMA here. 

In announcing the Final Rule, the Centers for Medicare and Medicaid Services (CMS) said that the final rule with comment period also includes a statutorily required 26.5 percent across-the-board reduction to Medicare payment rates for more than 1 million physicians and non-physician practitioners under the Balanced Budget Act of 1997’s Sustainable Growth Rate (SGR) methodology.

Nothing new to share here, but Congress has overridden the required reduction every year dating back to 2003. The Administration is committed to fixing the SGR update methodology and ensuring these payment cuts do not take effect.  It is highly likely that the reduction won't happen in 2013 either.  As always, everyone is put on edge and nothing happens.  We can only hope that we are not around when something does.  The unfortunate problem is that wherever Medicare rates end up, many of the commercial payors who use Medicare as a basis for reimbursement will likely follow suit with cuts, but it is doubtful they would impliment any increases. Most payors are looking for reducing reimbursement rather than making increasing fees that are paid out to their providers.  

Visit CMS' website to see the final rule with comment period here.  Additionally you can read the CMS fact sheet here.  The comment period closes on December 31, 2012.

If you are seeking assistance with Medicare Provider Enrollment.  Please click here for more infomation.  

Brian Agnew is President of Supero Healthcare Solutions a leading practice management company focused on provider enrollment and credentialing services for physicians and other healthcare providers.

 

Topics: Provider Enrollment, Payor Contracting, Payor Credentialing, Provider Enrollment Services, Physician Credentialing, Medical Credentialing, Provider Credentialing, Insurance Credentialing, Medicare Provider Enrollment

Provider Enrollment - Tips for Success - NPI Numbers (Step 4)

Posted by Brian Agnew on Thu, Jun 23, 2011 @ 16:06 PM

 

NPI Number, Provider EnrollmentNPI numbers are a key component of the provider enrollment, credentialing, or contacting process with the payors. Let's first understand what they are and why you need them.

The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated the adoption of standard unique identifiers for health care providers and health plans. The purpose of these provisions is to improve the efficiency and effectiveness of the electronic transmission of health information. The Centers for Medicare & Medicaid Services (CMS) has developed the National Plan and Provider Enumeration System (NPPES) to assign these unique identifiers.

The NPI number can be obtained online through the National Plan and Provider Enumeration System (NPPES) website.  Turnaround time for obtaining a number is usually very expeditious, which is normally unusual for a medical credentialing operation. NPI numbers can be searched on the CMS website listed in external links National Plan and Provider Enumeration System information from CMS.

Health practitioners need to have this number in order to receive reimbursement from insurance companies and to prescribe medicines. This is also needed to refer patients to other practitioners who particiapte with the health plans.

There are two types of NPI numbers.  Type 1, which is for the individual provider and Type 2, which is a number for the organization or business.

As outlined in the Federal Regulation, The Health Insurance Portability and Accountability Act of 1996 (HIPAA), covered providers must also share their NPI with other providers, health plans, clearinghouses, and any entity that may need it for billing purposes.

All individual HIPAA covered healthcare providers (physicians, physician assistants, nurse practitioners, dentists, chiropractors, physical therapists, etc.) or organizations (hospitals, home health care agencies, nursing homes, residential treatment centers, group practices, laboratories, pharmacies, medical equipment companies, etc.) must obtain an NPI for use in all HIPAA standard transactions, even if a billing agency prepares the transaction. Once assigned, a provider's NPI is permanent and remains with the provider regardless of job or location changes.

Other health industry workers, such as admissions and medical billing personnel, housekeeping staff, and orderlies, who provide support services but not health care, are not required to obtain the NPI.

The NPI must be used in connection with the electronic transactions identified in HIPAA. In addition, the NPI may be used in several other ways:

  • For health care providers to identify themselves in health care transactions identified in HIPAA or on related correspondence;

  • For health care providers to identify other health care providers in health care transactions or on related correspondence;

  • For health care providers who do prescriptions (however, the NPI will not replace requirements for the Drug Enforcement Administration number or State license number);

  • For health plans in their internal provider files to process transactions and communicate with health care providers;

  • For health plans to coordinate benefits with other health plans;

  • For health care clearinghouses in their internal files to create and process standard transactions and to communicate with health care providers and health plans;

  • For electronic patient record systems to identify treating health care providers in patient medical records;

  • For the Department of Health and Human Services to cross reference health care providers in fraud and abuse files and other program integrity files;

  • For any other lawful activity requiring individual identification

    If you need assistance in obtaining an NPI number for provider enrollment and credentialing, please click here contact our offices today!


Brian Agnew is President of Supero Healthcare Solutions a leading practice management company focused on provider enrollment and credentialing services for physicians and other healthcare providers.

 

Topics: Provider Enrollment, Payor Contracting, Payor Credentialing, Provider Enrollment Services, Physician Credentialing, Medical Credentialing, Managed Care Contracting and Credentialing, Credentialing

Provider Enrollment - Tips for Success - CAQH (Step 3)

Posted by Brian Agnew on Fri, Jun 10, 2011 @ 16:06 PM

CAQH, Provider EnrollmentOne area that seems to cause confusion during the provider enrollment or credentialing process is CAQH registry. First, let's understand what CAQH is:

The Wikipedia definition: The Council for Affordable Quality Healthcare is a non-profit alliance of health plans and trade associations, working to simplify healthcare administration through industry collaboration on public-private initiatives. CAQH strives to be a catalyst for industry collaboration on initiatives that simplify healthcare administration for health plans and providers, resulting in a better care experience for patients and caregivers.

Under the CAQH umbrella you have the Universal Provider Datasource (UPD).

The UPD is built around a single electronic form and secure database, this system enables healthcare providers to submit, store, update and access their most critical information for credentialing, claims processing, quality assurance and member services, such as directories and referrals. Payors authorized by providers participating in UPD can electronically download the information into their systems. This standard form meets the data-collection needs of health plans, hospitals and other healthcare organizations.

More than 890,000 providers in all 50 states and the District of Columbia and over 550 health plans, hospitals and other healthcare organizations currently use the service to streamline data-collection processes.

Bottom line is that it is a requirement if you are a professional seeking to become enrolled, credentialed, or contracted with many of the larger insurance carriers.  It is simply a place where all your information resides so that payers can access it whenever they need to.

Being registered with CAQH is a process that is ignited once you have started contacting payors.  Many require that you be registered with CAQH and normally you will receive a special CAQH registration kit provided by the payers, so that you may register on the CAQH website.  Without this registration kit, you can't register, so you need to ask for this when you first make contact with one of the larger health plans.

Once you receive this registration kit you can then proceed to the CAQH website and start the registration process.  You will need to ensure that you give the health plan access to your records. There is a question or two that allows you to authorize access and if you don't complete this step, it could delay the process.

You will normally fill out a separate provider questionnaire or request for participation in a payer network.  Once this is submitted and you are registered with CAQH, the payer can obtain all your credentialing information and then you are off to the races!

If you need assistance in CAQH registry, click here to contact our office today!

Next up - NPI Numbers!

Brian Agnew is President of Supero Healthcare Solutions a leading practice management company focused on provider enrollment and credentialing services for physicians and other healthcare providers.

 

Topics: Provider Enrollment, Payor Contracting, Payor Credentialing, Provider Enrollment Services, Physician Credentialing, Medical Credentialing, Managed Care Contracting and Credentialing, Credentialing

Provider Enrollment - Tips for Success - Be Prepared! (Step 2)

Posted by Brian Agnew on Tue, May 31, 2011 @ 21:05 PM

Provider Enrollment, Be Prepared, Stack of Paper

In the second step of the series, after choosing which contracts to pursue from payors like Aetna, BCBS, CIGNA, Humana, UnitedHealthcare, and Medicare.

The second step in this process is to be prepared!  I see so many providers that are ready to start, but can't put their fingers on any required credentialing documentation.

 

 

 Click here to learn more about provider enrollment/ credentialing assistance.

Here is a quick checklist that I recommend that you have ready before beginning the provider enrollment process:

  • Full Legal Name of Corporation

  • Practice Demographics (Address, Phone, Fax, Website, Contact Person, E-mail address)

  • Owner Information for All Owners (Need name, SS#, NPI#, Date of Birth, Place of Birth, Medicare #)

  • Federal, State, and/or Local professional licenses, certifications, and or registrations for the company

  • IRS CP575 Form (This is the official document with Tax ID#)

  • W-9 (Physical Address)

  • W-9 (Billing Address)

  • Curriculum Vitae (CV)

  • Date of Birth

  • Place of Birth (City, State, Country)

  • Copy of Drivers License

  • Social Security Number

  • Copy of Professional Degree(s, Certifications, and/or Evidence of Qualifying Coursework(Needed for Medical Directors and all Owners)

  • State Medical License

  • Board Certification(s)

  • General Liability Insurance (Facesheet)

  • Professional Liability Insurance - Malpractice (Facesheet)

  • Malpractice History (Very important!)

  • DEA and/ or Controlled Substance Certificate

  • Copy of ACLS

  • Billing Company Information (If Applicable)

  • Letter from Bank (This is sent to Medicare to verify that a bank account has been setup. Needs to come from a bank representative with account information outlined.) A voided check is also acceptable.

  • Copy(s) of all CLIA Certificates, FDA Mammography Certificates, and Diabetes Education Certificates, (If applicable)

  • Copy(s) of all State Pharmacy licenses, (If applicable)

  • Hospital Privileges (If applicable)

Seems like a long laundry list of items, but I assure you, if you have this ready to go from the start, this will make life easier and you will complete your provider enrollment much quicker.

If you need assistance with the provider enrollment process, click here to contact our office today!

 

Brian Agnew is President of Supero Healthcare Solutions a leading practice management company focused on provider enrollment and credentialing services for physicians and other healthcare providers.

 

Topics: Provider Enrollment, Payor Contracting, Payor Credentialing, Physician Credentialing, Medical Credentialing, Provider Credentialing, Insurance Credentialing, Managed Care Contracting and Credentialing

Provider Enrollment - Tips for Success - Choosing Contracts (Step 1)

Posted by Brian Agnew on Tue, May 31, 2011 @ 21:05 PM

Normally when I start a provider enrollment project for a client, the first question I get from the provider, is "which contracts do I need be credentialed for in my market."  There are the usual payers like Aetna, BCBS, CIGNA, Humana, UnitedHealthcare, Medicare, Medicaid, and TriCare.provider enrollment

These are usually a good rule of thumb to start with in nearly any major market.  Beyond these, you will usually see a local plan or two that you might want to contract with as well.

The number of contracts is not as important as the quality of contracts.  

For the normal practice, you might see 15% to 25% of your patients through Medicare or Medicaid depending on the population you serve and where you are located. After that, it is normally 7 or more commercial payors that will drive 70% or more of your patients to your practice.

Two contracting vehicles to be aware of are a PHO (Provider Hospital Organization) or an IPA (independent Physician Association).  Many of these types of contracting entities can offer up to 20 plans as part of their contract offering.  With this kind of model, the provider fills out one application and signs one contract.  This is good, because it cuts down on the amount of paperwork.  The downside is that these entities don't usually have contracts with the large payors.  It will be an opt-in/ opt-out scenario in which the provider chooses which plans to participate. If the plans you want are not included as a choice, you will need to pursue direct contracts with those insurance companies not included.

Another tip for choosing contracts is to see who your referring physicians are contracted and credentialed with.  If you are a practice that markets to another practice for referrals, one of the first questions your marketing person will get is what health plans are you contracted with.

If you don't really have a way of knowing which plans to contract with, there are consulting groups such as our company, who offer provider enrollment services and can help you develop a contracting strategy.  

If you need assistance in choosing which insurance companies to contract with, click here to contact our office today!

Brian Agnew is President of Supero Healthcare Solutions a leading practice management company focused on provider enrollment and credentialing services for physicians and other healthcare providers.

 

Topics: Provider Enrollment, Payor Contracting, Payor Credentialing, Provider Enrollment Services, Physician Credentialing, Medical Credentialing, Managed Care Contracting and Credentialing, Credentialing

Welcome to Our Blog!

Posted by Brian Agnew on Mon, May 23, 2011 @ 20:05 PM
Welcome

Hello! Welcome to our blog and thank you for coming.  

This blog is place for us to communicate our thoughts and pass on observations that we see in the day to day work surrounding payor contracts and payor reimbursement.  

We come across a ton of good information as well that we think people need to know. 

We get many questions about how things are supposed to be done in this overly complicated process of being a network provider, so we thought we would share our knowledge with anyone who will listen.

We specialize in provider enrollment, contract underpayment, managed care contract negotiations, contract modeling, credentialing, and other payor related services.

So, if you are a provider or professional delivering healthcare services and deal with the payors, we think you will appreciate our insight.

Sincerely,

Brian Agnew

President

Supero Healthcare Solutions

Brian Agnew is President of Supero Healthcare Solutions a leading practice management company focused on provider enrollment and credentialing services for physicians and other healthcare providers.

 

Topics: Welcome