Best Practices – Clinical Documentation Improvement

All healthcare facilities – irrespective of whether they are a business enterprise or a charitable institution – have to be financially viable in order to continue to provide services.  Clinical documentation improvement (CDI) programs have evolved from being an informal part of the process to becoming the backbone of the facilities financial viability.  Essential for patient safety and care, quality ratings, accurate reimbursement and reduced physician queries, CDI programs are required and necessary for consistent and complete documentation.  With the transition toICD-10, documentation integrity becomes critical as it gives an accurate image of clinical severity along with providing medical justification for MS-DRG and code assignments.

In order to enjoy the full benefits from ICD-10 and meaningful use, data collection techniques have to improve with healthcare providers looking at data collection as a comprehensive initiative to ensure effective and safe patient care.  While many large healthcare facilities have invested in automated systems to improve clinical note taking, there are a number of things that the smaller practices can follow to ensure best and accurate clinical documentation.

Create guidelines for best practice

The most important step to clinical documentation improvement is to create guidelines that match the best practices and industry standards.  The aim is to provide clarity and brevity while keeping the needs of other readers in mind.  According to the American College of Physicians, practices should define guidelines based on “consensus-driven professional standards unique to individual specialties.”

Constant training and education programs

Your staff may be familiar with documentation standards, but in this rapidly changing healthcare environment, it is important that they upgrade themselves regularly.  Training should be an ongoing process as there are constant upgrades and improvements to EHR software, changes in regulations and the requirements of payers.  Constant and regular training will definitely improve the skill level of your staff in not just documentation but also in identification and rectification of problems.

Appoint a physician advisor/champion

A good way to reduce the practice’s reliance on vendors and third party trainers is to appoint a physician advisor/champion to spearhead the CDI program.  The advisor needs to be enthusiastic about the program, complete knowledge of best documentation practices and a good role model.  The advisor is the core of the program – someone who is there to answer questions from other physicians and support staff.  The effectiveness of the CDI program will depend a lot on the advisor’s drive and commitment to the program.

Monitor performance metrics

Although CDI programs help improve the financial viability of the facility, this alone is not a metric to measure the effectiveness of the program.  To really benefit from the program, it is important that the following performance metrics are monitored.

• Number of cases reviewed and time spent per case
• Physician response rates
• Agreement / disagreement rates of physicians
• Response time to queries
• Expected versus observed death rates
• DRG shift rates.

The facility also needs to analyze these results to find out which physicians are queried most often and which diagnosis is queried the maximum – there may be a need for further education/training for physicians / coders.

More access to EHRs for patients

Making mistakes is human and it is inevitable that physicians will make documentation errors at times.  Allowing greater access to patients to review their medical records helps in finding these errors.  Making use of technology, to allow patients to review their medical records on an online portal can and will help the facility to improve the accuracy of its documentation.  As it is, according to the requirements of Stage 2 Meaningful Use, allowing patients access to their medical records is mandatory – why wait to implement the same.

3 Steps To Creating Your Clinical Documentation Improvement Program

Improving clinical documentation leads to revenue gains and most healthcare facilities are now exploring this program.  The main reason for getting into this program is to improve your reimbursements and that will happen with improved documentation and coding.  However, it is important to set specific goals when putting together a Clinical Documentation Improvement (CDI) program for your facility.

Here are some goals that you can keep in mind when building your CDI program:

• Aim for your facility to become well-organized
• Improve quality of patient care with reliable medical records.
• Clarify coding and documentation with an established query process
• Work with the provider to establish documentation expectations
• Schedule audit and monitoring on a regular basis

It is important to understand the three processes that you need to take into consideration, in order to create an effective and manageable CDI program – assessment, implementation and maintenance.

Assessment

Healthcare facilities establishing a CDI program need to perform an objective assessment on the existing quality of documentation and coding.  It is important to understand if the deficiencies are due to ambiguous documentation, lack of physician documentation or coding interpretation issues.  Evaluate if your current system is in place for clinical documentation

• Identify areas that may require improvement or corrections through a baseline medical record audit
• Assess physician education and training for the CDI program
• Analyze your payment and denial pattern and set specific goals for the providers and your staff
• Separate audits for therapeutic and diagnostic procedures
• Keep focus on level 1-5 visits, not just level 4 and 5
• Choose a model based on your requirements
• Bell curve data and practitioner utilization to be reviewed

Implementation

• Bring your staff on board and make them aware of the importance of each task
• Ensure that everything required for implementation – work space, tools, personnel are in place
• Establish a training program and encourage CDI orientation for staff credentialing
• Implement changes based on your audit
• Work with your CDI provider to set up a customized program based on the audit results
• Identify areas requiring further improvements or corrections
• Develop compliant, meaningful queries and assign a staff to monitor and manage them

Maintenance

• Set up a monitoring schedule with the provider
• Set up regular training and education programs for the staff
• Conduct additional audits regularly to find areas that need improvement
• Work with the provider to make adjustments to the program, based on the audits

A successful CDI program promotes complete, accurate and compliant documentation; established through analysis and interpretation of health record documentation. This in turn leads to identification and rectification of situations where there is insufficient documentation to support the patient’s care.  Staff needs to be trained to formulate physician queries, analyze data and monitor the program’s performance.  In addition they also should be able to communicate with HIM staff, administrators and physicians successfully.

Contact us at info@medconverge.com for assistance with your clinical documentation.

3 Financial Mistakes Made by Young Doctors

“Money makes the world go round” – and it can make you go round in circles too, if you make financial mistakes.  This is one part of our existence, where even age and experience are no guarantee for not making mistakes.  Having said that, youth and inexperience create more chances for making financial blunders than the old and wise.  Young physicians too are equally susceptible to making financial mistakes and need to be extra careful when dealing with those typical physician-specific traps.  Given below are three common mistakes that young doctors have been found to make in their initial years of practice.

Taking whatever terms are offered

The lure of making big money and the fear of not getting another offer makes young physicians agree to whatever terms the potential employer offers, without realizing the long term implications of such an offer.  What is important to you – money, work schedule, time for family – you need to prioritize your requirements.  Check whether the terms offered match your priorities before you accept the job.  However, you need to be clear about your “wants” versus your “needs” and understand the difference between the two.  While your needs require fulfillment immediately, your wants can be fulfilled in the long term. 

Depending on your needs and priorities, negotiate firmly but respectfully to ensure that you get what you deserve.

A lot of young physician’s who made the mistake of not negotiating or not setting their priorities early in their career, now rue the chance they lost.  While some of them are trying to reorganize their careers or look for a different job; some have resigned themselves to what they have.  Thus, it is important to be confident and negotiate terms that will support your priorities – this will make your career a rewarding and happy one.

Spending more than you earn

Most young physicians are already in debt by the time they graduate.  Covering the cost of tuitions and boarding, this debt could be as high as $200,000 for most.  The salary as a resident doctor (while completing your training) may not be enough to service the interest on the debt.  By the time you are starting out on your career, you are already neck deep in debt.  This is the worst time to spend money on your wants – be it a car or a house of your own. While there is no doubt that you will be earning from now on; the last thing you want to add to an already existing debt is additional mortgage payments.  This is the time to ensure that your needs are fulfilled – your wants can wait for a few more years.

The first priority for young physicians should be to pay off their student loan debt.  That would mean living the lifestyle of a resident for a few years more.  This would also allow them to increase their savings rather than getting further into debt.  While it is tempting to spend money on your wants, it adds to the pressure of making ends meet which will eventually start telling on your personal and professional life.

Investing without understanding

Money kept idle and not invested, will eventually shrink in value.  However, money invested without understanding and knowledge will definitely shrink in value.  Just because you have become a doctor does not automatically qualify you to become a knowledgeable investor too.  There are many young doctors who have made this mistake and paid heavily for it.  You are earning good money and you wish to make it better – get yourself a professional investment advisor.  However, do not blindly follow the advice; instead do your own research on his advice and educate yourself on the intricacies of financial investment.

Remember, there are no free lunches – what may be attractive as a “tax free” investment would not necessarily be “cost free”.  Cost of investment plays a major part in average and good returns – not everything that is tax free is necessarily good investment.  A good investment portfolio is a mixed bag on tax deferred products, tax free products and taxable products.  This translates to products such as 401(k) or 403(b), stocks and mutual funds.
Remember, investing wisely and keeping a leash on your spending will ensure that you are financially stress free throughout your career.

Increase Your Medical Practice Revenue With These 15 Tips

Times are tough – reimbursements are declining and expenses increasing.  Keeping your practice viable in this environment requires being able to identify areas in your medical practice which are bleeding money and working out a strategy to stem the bleed.  While each practice will require a different strategy to boost its bottom line, here are some tips that all medical practices can follow.

Make your entrance attractive and inviting: A visually appealing entrance will be more attractive to patients than a dingy and plain looking one.

Enliven your reception and waiting area: Brightly painted walls, current periodicals, comfortable chairs and maybe free Wi-Fi to make your patients wait comfortable.

Ask patients to write online reviews: Positive reviews from existing patients will encourage new patients to come to you.

Use social media to interact with the community: Connecting with your community through social media can make people comfortable with coming to you when they need a doctor.

Use the power of the internet: Create your webpage and publish blogs, knowledge articles etc.  Patients tend to prefer doctors who reflect authority about their profession.

Organize patient education meetings/classes: Organize meetings/classes on issues such as living with diabetes, pros and cons of dieting, ways to quit smoking etc for your patients and others.

Train your staff: The patient is the reason why your practice runs – train your staff to be courteous, efficient, helpful and caring to the patients needs.

Make your practice paperless: Automating your processes will save you money and time– bring in and implement an EHR system.

Create more appointment options: Is it feasible for you to see patients in the evenings or during weekends? Can you manage a visit to the patient’s residence if required? If yes, these will definitely add to your revenue collection.

Offer more services: Add services like alternative medicine, physical therapy, wellness spa etc. to your practice. These can bring in additional revenue; however, a thorough cost versus benefit evaluation is a must before starting them.  Take a look at this post on Ancillary Services.

Negotiate payer contracts: It is important to review your payer contracts annually.  Renegotiate contracts at the time of renewal and add new payers to your current list.

Review and analyze your bills and medical claim denials: Make it a practice to regularly review and analyze bills raised by your office, along with denials from payers. Put corrective measures in place and ensure that these are followed.

Rework prices with vendors: Talk to your vendors and ask for discounts on bundled services.

Outsource wherever possible: Outsourcing work like billing and collection will definitely be cheaper than doing them in-house.

Encourage group purchasing and avoid overstocking: Join a group purchasing organization or start one in your neighborhood with other practices to reduce cost of regular supplies. Keep an eye on your inventory to ensure that you are not overstocking supplies.

ICD-10-CM Code (M62.84) for Sarcopenia Announced

Effective October 01, 2016, the code M62.84 will be used by the healthcare community for sarcopenia, thus recognizing it as a distinctly reportable condition.  The AIM (Aging in Motion Coalition) announced this ICD-10-C code, as established by the CDC (Centers for Disease Control and Prevention.

What is Sarcopenia?

Defined as a combination of low muscle mass, coupled with weakness in older people; sarcopenia is the progressive loss of skeletal muscle that comes with aging.  While most adults begin losing some amount of muscle mass after crossing the age of 30, there is an exponential loss of strength as the person gets older.  Believed to play a major role in functional impairment and increased frailty, sarcopenia can cause problems with mobility due to decreased muscle strength, increase the chances of falls and resulting fractures, induce frailty hence reducing activity levels and bringing about a loss of independence due to impaired physical mobility.

Why is this code important for sarcopenia?

The recognition of sarcopenia as a distinctly reportable condition in the eyes of the international medical community removes a major barrier for its treatment and research.  Doctors will now be able to improve their diagnosis of this condition; while there will be more recognition by other healthcare professionals of the disease.  With more comprehensive data like EMRs, Death Certificates etc., regarding the disease, researchers will be able to establish universal guidelines for clinical diagnosis and treatment of sarcopenia.  Opening the doors to further research, this code could lead to the acceleration of new therapies for the disease.

The Aging in Motion (AIM) Coalition

A diverse group representing providers, caregivers, patients, consumers, researchers, employers, aging Americans and the health care industry, the Aging in Motion Coalition works towards pressing for higher research and innovation to develop treatments in sarcopenia and other age related functional decline amongst the old.  AIM Coalition was initiated by the Alliance for Aging Research and has been leading interactions with various stakeholders like regulators, clinicians and policy influencers to establish their goals.  One of their primary founding goals was to realize an ICD-10-CM code for sarcopenia – which lead to their submission of a proposal to the CDC in 2014.  Their efforts have resulted in the establishing of the ICD-10-CM code for this condition.

For assistance with your medical billing and medical coding requirements, contact us at info@medconverge.com

Stop Revenue Leaks in your Medical Practice

Managing your healthcare revenue cycle is never easy.  Revenue leaks can create havoc with your organizations financial viability.  The root cause of revenue leaks are generally internal, with someone in the system or the system itself, not performing correctly or efficiently.  According to Marc Lion, CEO of Lion & Company CPAs, the average medical practice has a 10 to 15 percent profit leak.

However, the good news is that revenue leaks are preventable with analytics and diligence. Given below are three ways to stop revenue leaks in your medical practice.

Monitor your payments

It is very important to monitor your payments regularly – in fact; it should be part of a weekly schedule.  Despite all the advancements in information technology, errors on medical claims by commercial insurance companies average7.1%, according to the AMA (American Medical Association).  Medical business office associates will key into the billing system what is written on the paper.  Any mistake or undercharge made at your end is going to be reflected as it is and that will definitely hurt your bottom line.  One way to ensure that there are no underpayments is by obtaining the rates directly from the insurance company.  Make sure that you are aware of each rate at the time of negotiating the contract and also when your renewal comes up.  Ask the insurers representative to clarify all your doubts and answer all your queries regarding the reimbursements.

If the rates offered do not match your expectations, negotiate with the insurance company.  You can always get better rates for services that few can perform in your area.  Be sure to check the accuracy of every payment at the CPT code level.  Your system needs to be fed the current fee schedules for you to benefit from them.

Review your denials regularly

It is so much easier to write-off denied payments than to pursue them – and this does happen.  The only way to ensure that your denials keep reducing is to review them regularly.  Is there a pattern to your denials?  If yes, what steps can be taken to ensure that they are not repeated.  Each and every denial needs to be reviewed and pursued; even better if you can do this on a weekly basis.  Bring everyone connected with the denials into the loop and chalk out steps that will ensure that the same mistake is not repeated.  Only if you find that the denial cannot be pursued any further, allow it to be written off.  It is also important to remember that there are time limits for appealing denials.  Make sure that you do not allow this travesty to take place.

Set guidelines in place for everyone involved with medical billing and claims.  Establish a medical claim denial management procedure that has to be followed to the letter.

Time is money

You have worked hard to reach where you are and your time is your biggest asset.  Time is money and wasted time means lost revenue.  Ensure that your office is prepared to fully utilize the time of the day – set up a system that makes efficient use of everyone’s time.  Time lost in searching for something that is not where it should be, hunting for records after a patient is sitting in front of you, trying to find an associate when you already knew that he would be needed – all of these activities cost you precious time and even more precious revenue.

Create a work flow for your staff, make sure that your supplies are all kept in the appropriate place; records need to be placed in the proper files and drawers – these all seem like basic tasks, but believe me, this is where a lot of practices lose time.  It pays to train your staff to work at the peak of their license – from receiving phone calls to preparing the patient for an examination.  The smoother things move, the more number of patients can be accommodated and more patients translate into more revenue.

In a nutshell

These are the key steps to ensure that you do not leak revenue in your medical practice.

1. Identify all factors involved with your revenue generation and review them regularly.
2. Mark control points in your revenue stream.
3. Establish guidelines and measures and make sure they are followed.
4. Monitor denials regularly and set up a denial management program.
5. Optimize solutions and execute them.

While it may take time to stem the revenue leakage, it is worth the time and effort required to put these steps in place.  Managing your revenue is an ongoing process that requires regular interventions and changes to match the requirements of the marketplace.  In the end you will find that the results far outweigh the work put into it.

Florida Hospital Gains $72.5 Million Courtesy its Clinical Documentation Improvement Program

Once an informal process that received significant attention at just a few hospitals; Clinical Documentation Improvement (CDI) is now the backbone of an organizations financial viability.  Essential for patient safety, proper and accurate reimbursement, quality ratings and more, a strong CDI program will ensure documentation integrity – a key factor in the ICD-10 transition.  Organizations that seek to improve the efficiency and effectiveness of their CDI programs will find that the rewards are immense.  The benefits received by Florida Hospital stands testimony to this fact.

Healthcare IT News reports that Florida Hospitals implemented the CDI program in 2014 and by May 2015 and completed an expansion across eight affiliated hospitals.  Pre 2014, the observed-to-expected mortality rates for the hospital stood well above the national average.  According to the hospital this was due to gaps and errors in clinical documentation.  Within a year of implementing CDI, the mortality rates were reduced by a whopping 48% – a result of accurate documentation of the disease acuity of the patients at the hospital.  Today, the hospital stands in the top quartile of the industry average.

Florida Hospital aimed towards improving their case mix index by eight basis points through the implementation of more accurate and complete clinical documentation of care delivered to its patients.  By fall 2015, the hospital’s case mix index basis points, which are worth approximately $2.5 million a year for the hospital, had risen to 1.88 basis points from 1.59.  This increase in the case mix index basis points translated to an increase of $72.5 million in appropriate reimbursement.

In a nutshell, Florida Hospital reduced mortality rates by 48%, improved its case mix index, achieved ICD-10 compliance and increased its reimbursement earnings by $72.5 million – all due to its CDI program.  According to the hospital, increased integrity of its clinical documentation, better accuracy and physician engagement are the reasons for their clinical and financial improvement.

This documentation initiative was driven by educating and engaging 20% or 2,200 medical staff at the hospital.  Physician response rates to CDI clarifications stood between 87 and 92 percent.

Florida Hospital plans to expand their CDI program, using the framework to provide a more efficient workflow for their clinicians and clinical documentation specialists.  Integrated into Cerner’s Document Quality Review platform, computer assisted physician documentation technology will provide physicians with automated CDI clarifications.

According to the American Health Information Management Association (AHIMA), “Successful CDI programs facilitate the accurate representation of a patient’s clinical status that translates into coded data.  Coded data is then translated into quality report cards, physician report cards, reimbursement, public health data and disease tracking and trending.”

Florida Hospital would agree with that.

ICD-10 codeassist services

The main reason for the transition from ICD-9 to ICD-10 was greater documentation precision.  However, if the diagnostics is documented by clinicians at a lower level than what ICD-10 supports, it may result in submission of financial claims that are lower.  Such documentation will also cause a patient’s medical record to lack details, resulting in incomplete information for future providers.  In order to help resolve these problems, a clinical decision support (CDS) system can be designed for ICD-10 awareness which improves coding data capture and helps deliver ICD-10 specific clinical documentation improvement (CDI). Here are some highlights from a  recent article published in ADVANCE by Dr. Strongwater.

Why do you need a CDS system for ICD-10?

The biggest advantage of a CDS system is that it rides on top of the EMR system where it can align clinical decision making with evidence based best practices, thus strengthening the documentation at the very moment that it is recorded into the EMR.  With capabilities to align clinical documentation with ICD-10 at the time of recording and alerting clinicians of the chance to utilize more specific ICD-10 codes; the CDS system is a great help to clinicians as it does not require them to memorize and remember the current expanded ICD-10 code set.

The CDI helps in creating a more specific medical record of the patient and allows for submission of a cleaner and complete claim to help the provider with receiving their just dues.

Required CDS capabilities for ICD-10 CDI

In order to be accurate with its CDI, the CDS system must have the ability to not only read, but also interpret structured documentation as well as unstructured free text notes in the patient’s EMR, along with the capability to collect and interpret information coming from test labs and imaging departments.  While the ability to read clinical documentation at the recording stage is important, it is more important for the CDS to analyze this documentation relative to its knowledge of the patient and issue corrections to the clinician in real time.  A great addition would be providing a pop-up suggestion box within the EMR screen, if there is a need for more details or a change in the reimbursable code.  This pop-up box should have the correct code or higher level of detail that can be captured by the clinician from here itself.

One of the biggest advantages of the CDS system is alleviating the need for clinicians to master ICD-10 codes.  However, what would help enhance the system even more would be the ability to generate a report that indicates which documentation suggestions were ignored by the clinician.  Not only would this help the billing department close any ICD-10 gaps that remain, but would also help in procedure improvements and help the facility to adjust to ICD-10 completely.

Value of the CDS system

The EMR which just records and acts as a repository mechanism for a patient’s medical data is elevated to become a real time advisory system by adding the CDS system.  This allows for streamlining the processes, improving patient safety and result in less time taken and lower costs.  The CDS system delivers value by providing suggestions of best practices along with a complete clinical record of the patient, thus delivering quantifiable clinical and operational benefits to the organization.

5 Commonly Used Healthcare Revenue Cycle Management Terms

One of the key components for healthcare providers and facilities, healthcare revenue cycle management can be intimidating and confusing for a lot of people.  Statutory requirements, coding and billing, payments and denials – add to these the various terms and acronyms that are used – and you have a mine-field on your hands.  Given below are five commonly used healthcare revenue management terms along with a short description of what they mean.

Alternative Payment Models

The traditional method of paying healthcare providers through a ‘fee for service’ model, allowed the system to be misused.  Payments under the ‘fee for service’ model were made for any tests conducted or any service provided, at a pre-negotiated rate for each activity.  This created an incentive for healthcare providers to ask patients to undergo tests or services, which they may not have required for their treatment.  A simple example is a patient who comes with a coughing problem – the first tests that could be asked for is a chest X-ray and a complete blood test, which may not be required at all in this case.  In order to put a stop to this financially draining and open to abuse system, alternative payment models have been developed by healthcare reformers.  Creating incentives that favor quality of service over quantity, these models include bundled payments, ACOs and value based reimbursements.

Bundled PaymentsAs the term denotes, this is a single payment covering all services and tests delivered to a patient suffering from certain acute medical conditions, over a specific time period, covering the full episode of care.  One of the key components of this model is the sharing of a single payment by multiple providers for the different services they administer in a single episode of care.  The healthcare reformers believe that this will bring about better and more dynamic relationships between different providers.  Organ transplants, knee and hip replacement and other similar procedures are some of the many services that are being paid by insurers under the bundled payment model.

Accountable Care OrganizationA coming together of different members of the healthcare community like hospitals, testing labs, doctors etc, under a single umbrella to share responsibility and provide care to a population of patients, an Accountable Care Organization(ACO) delivers coordinated care, which can result in a reduction of unnecessary medical tests and services, higher savings for providers and better health outcomes for patients.  Value based payment models tied to quality metrics, create incentives to provide cost effective and quality healthcare.

Value based reimbursementDriven by Medicaid, Medicare and other commercial payers, value-based reimbursement is directly linked to quality of care and patient outcomes.  Under this system, costs related to unnecessary or excessive tests and services shifts back onto the healthcare providers – thus ensuring that they have no incentive to ask for or provide more than what is required.  Healthcare reformers believe that this will eventually result in superior quality healthcare minus the inefficiencies, redundancies and fraudulent services.

Price transparencyConsumers are becoming more demanding about knowing in details how much the treatment would cost, as it would allow them to take better informed decisions regarding their treatment.  With increasingly high deductibles and out-of-pocket copayments, consumers want accurate data about the costs involved in their treatment.  However, in many cases, it becomes difficult for the healthcare provider to offer this data as they need to negotiate with payers on pricing.  An ACO for example, would be dealing with multiple payers and different price variations.  Price transparency is becoming an important aspect of the healthcare industry revenue cycle.  The lack of price transparency will eventually lead to trust issues between everyone involved.  Healthcare reformers feel that price coordination between payers and providers is as important as care coordination – something that can be achieved through Accountable Care.

Benefits of Outsourcing Provider Credentialing And Enrollment Services

Healthcare facilities address the health needs of people and are supposed to treat the sick under all circumstances.  However, for any organization to remain viable and continue to provide services, it needs to be paid for the services provided – fully and in time.  In order to receive their just dues, organizations have to work with various payers, for example payers like Medicare and Medicaid.  Payer enrollment, till a few years back, was not considered necessary by healthcare professionals as important for building their practice.  Today, however, it is not just necessary, but nearly imperative for clinicians to be enrolled with insurance companies.

With the coming into being of the Affordable Care Act, people who were previously without any health insurance, now have access to healthcare coverage.  This, along with the desire and demand of the majority of patients and their families to utilize their health insurance to pay for healthcare services received rather than paying it out of their own earnings, has made it crucial for healthcare providers to enroll themselves with the payers.

Unfortunately, provider credentialing and enrolling with the payers is becoming more difficult with each passing day.  With most insurance panels getting overloaded due to the spurt in membership applications and a lot of them being selective about enrolling providers, the process of enrolling your facility is becoming more challenging.  Under the circumstances, outsourcing your credentialing and enrollment not only looks as an attractive option but also makes financial sense.

Benefits of Outsourcing Credentialing and Enrollment Services:

• Reduces operating costs which can typically be around 30-40%.
• Eliminates errors which could lead to delays in your enrollment.
• Gives you the advantage of getting experts to do the job.
• Allows your staff to concentrate on billing and collections.
• Gives you more time to concentrate on your patients and building your practice.
• Saves you tons of paperwork and hours of frustration.

Remember, enrollment is necessary to remain monetarily viable, however, your practice was started to treat patients.  That is the core competency of your business and anything else can and should be outsourced to allow you maximum time to do what you do best – help sick people get better.

Difference Between Provider Credentialing and Provider Enrollment

Hiring incompetent healthcare providers or allowing them to remain with your facility can lead to increased liabilities in malpractice suits.  In order to ensure that your facility does not suffer from this, it is important that credentialing and enrollment of your providers is managed properly and kept up to date.  Failure to do so can and will have a negative impact on your revenue cycle.  Add to this, the regulatory requirements under which your facility can be at risk of compliance violations.

To ensure that your provider credentialing and enrollment processes are managed properly, it is important to understand the difference between the two.

Provider Credentialing

Credentialing refers to the process of verifying the proven skills, training and education of healthcare providers.  Verification of the providers credentials are done by contacting the “Primary Source”, which has provided the license, training and education.  The credentialing process is used by healthcare facilities as part of their hiring process and by insurance companies to allow the provider to participate in their network.  Credentialing is also the validation of a provider in a private health plan and the approval to join the network.

Provider Enrollment

Enrollment refers to the process of requesting participation in a health insurance network as a provider.  The process involves requesting participation, completing the credentialing process, submitting supporting documents and signing the contract.  Enrollment is also the validation of a provider in a public health plan and the approval to bill the agency for services rendered.

Importance of Provider Credentialing

Provider credentialing dates back to 1000 BC, and has been an important if not critical part of healthcare services.  The process of credentialing has undergone many changes over the centuries; however, the content of credentialing has remained the same – a verification of the education, training, experience, expertise and willingness to provide medical services by the provider.  It was around 1990, that national organizations started which were dedicated to the credentialing of medical providers.  Around the same time, the National Committee for Quality Assurance (NCQA) set guidelines on the process and method of credentialing medical providers.

These guidelines ensure that healthcare providers have undergone stringent scrutiny with regards to their ability and competence, thus making sure that the patients receive the highest level of healthcare.  For a patient, it is assuring and confidence boosting to know that your healthcare provider’s credentials are certified as through the credentialing process, thus ensuring that you are in good and competent hands.  For the provider, it states that their colleagues are held to the same standards as them.  For the healthcare facility, it shows that they value quality care and place the patient’s well being as a primary goal.

It is very important to remember that in today’s world of health insurance and revenue cycles, improper credentialing can lead to delayed or denied reimbursement for services provided.  Worse, it could lead to serious consequences for all concerned in terms of statutory compliance violations, which can result in monetary damages and criminal charges.

Provider credentialing and enrollment has been overlooked as an important component of healthcare management practices for years.  However, their impact on compliance issues and financial aspects to a practice has ensured that these are now key components to any thriving practice.

MedConverge Provider Enrollment and Credentialing Services can help you reduce your on-hold claim values, streamline and standardize administration processes as well as save time while ensuring compliance.  For further information, please contact: info@MedConverge.com