The relationship between payers and provider credentialing teams is an important one to nurture. Efficiently credentialing a provider with an insurance company ensures that the clinician is reimbursed for their services. If there are mistakes or questions, this can lead to delays and/or the provider not being paid for their work. Maintaining healthy relationships with these insurance companies ensures a better chance of success and few hiccups along the way.
We sat down with Amy Aymar, Manager of Credentialing Operations at Modio, to learn more about why relationships with payers are so important for credentialing teams and how they can work to make them valuable and steadfast.
Amy Aymar: Payer enrollment (aka provider enrollment) is important because without it, nobody gets paid! It is a necessity for hospital systems so that they will be reimbursed for patients that are being seen at their facilities. The definition for payer enrollment is the process of enrolling providers with health plans. The providers must be enrolled and in network with those payers to be paid for the services they provide to their patients. The concept sounds easy enough; however, payer enrollment can be complex, at times difficult to resolve, and have some major downstream impacts on revenue.
Amy Aymar: There are so many variables that go into payer enrollment, which is why it can be so difficult at times. A streamlined approach to this challenge is to help manage your provider’s profiles through various portals so that the payer enrollment process goes smoothly. The main portal that payers will utilize is CAQH (the Council for Affordable Quality Healthcare.)
CAQH is a good place to start to familiarize yourself with the various data points that payers will require for their credentialing processes. CAQH is a universal database that is utilized by multiple payers to gather enrollment and credentialing data. Payers will utilize CAQH often for recredentialing and demographic updates, so it’s best to be proactive with your CAQH re-attestations for your providers every 120 days.
Some payers will have their own applications that the credentialer will need to complete or an online application that will be submitted directly to the provider (not via CAQH). On average the payers will request around 15–20 data points; however, this can vary by state requirements and payer. The payers have their own internal credentialing process, so they may gather a lot more than what is sent to them — however, a baseline of information is required for them to start their process.
Amy Aymar: Best practice for payer enrollment is to try and give them as much data as possible — going beyond the basics. Every payer has different requirements for documentation, so it’s really important to know your state regulations, local payers that your patients may have, and what kind of documents they need upfront.
Additionally, your providers should be aware of any disciplinary actions taken against them so that they are prepared to provide documentation. For example, if your provider has a report in the National Practitioner Data Bank (NPDB) for malpractice, be prepared for the payer to request that. It’s important to know your providers and their situations as much as possible so that you can successfully set up the payer that’s enrolling your provider.
Amy Aymar: Definitely, a robust tracking system as part of a cloud-based platform with provider data storage is the ideal solution, such as Modio’s OneView. If you don’t have access to a system like OneView, it’s important that you keep your detailed notes from every interaction with the payer.
At the payer level, there are thousands of people working in these departments, and not everything is automated. Documents and application submissions have the potential to be lost. However, if you have that proof to back up your efforts, you will be more successful.
Amy’s Pro Tip: Ensure that you receive a call reference number (e.g., the rep’s name that you’re speaking to and the date or an actual reference number) when you’re connecting with a payer for a status check.
Amy Aymar: Modio timestamps your notes for you automatically, so you can see the dates and times of all correspondence. If you’re working off a spreadsheet, it’s really difficult to manage those details, even with good notes. Working with a system that automates the audit trail and communication details is helpful and removes an extra step for credentialing teams.
The way that Modio’s platform organizes the provider and payer data helps you easily manage the process and is an advantage that not many other credentialing platforms have. Being able to quickly glance at a provider’s profile and easily understand the story of the enrollment helps simplify a complex process.
Amy Aymar: Give them as much information as they need, try to anticipate any questions or any holdups that you would have with the application, and also, just try to understand where your payer contacts are coming from. While it may be frustrating for you as to why something’s not moving quickly enough, if you have a good relationship with your contact and you trust them, you know that they’re treating the issue with as much priority that it deserves.
Amy Aymar: Standardized processes across the board, no matter what kind of credentialing services you’re doing, are so important. Patience is also key. This is not an easy role, especially as a manager. Payer enrollment can be challenging, so engage and invigorate your team and have some fun with it. A lot of the credentialing process is archaic, so it’s important for a manager to think of innovative ways to enhance credentialing and keep that process moving forward and positive. Also, aligned communication with your team is crucial. There are many moving parts to the process, and clear communication can help alleviate frustrations between the team, providers, and payers. On a manager level, don’t be afraid to gently push back. Don’t take a denial upfront as, “All right, this is done.” Be proactive, persistent, and kind to find solutions.
Amy Aymar: National Association of Medical Staff Services, Centers for Medicare and Medicaid Services, the National Committee for Quality Assurance, and The Joint Commission are all excellent resources. Then, of course, Modio University! They cover some helpful topics!