Provider credentialing is intricate and complex. The depth of information that medical practices must be aware of, understand, and remain vigilant about in order to keep providers properly credentialed is vast. Credentialing is also vital in order for physicians and nurses to practice medicine and be compensated.
The rules and regulations vary across states and fluctuate from one payer to another. In the challenging world of credentialing, Modio Health’s Extended Credentialing Services (XCS) team emerges as unsung heroes for medical practices, helping them navigate the rules, regulations, and paperwork that come with any credentialing process.
We had the privilege of speaking with Amy Aymar, Credentialing Operations Manager at Modio, and Rachel Woodhouse, Senior Manager, XCS, to learn more about the important role they play in helping medical practices untangle the complexities of credentialing and enhance their operational value day in and day out.
Amy: We like to say that our team can take a provider, fresh out of school, and guide them through the entire credentialing process until they are ready to bill for services. We can get them licensed; affiliated with hospitals; and enrolled with federal, state, and commercial insurance payers.
Rachel: In some cases, a hospital will have a medical staff office that can help with some of these aspects, but to Amy’s point, if you don’t have an employer or group that helps or does it for you, the provider is responsible for all of it. If they don’t have a partner like Modio, the practice does it on their own.
Rachel: Unless you’re in IT and a software engineer, I don’t know many people that can build a software from scratch. A lot of people may not build software but do rely on Excel spreadsheets and Smartsheets. They’re trying to utilize basic tools to facilitate and keep track of everything. However, the more your practice grows, the more complicated credentialing can get. Spreadsheets do not have the features a credentialing software can offer, such as streamlining your process, organizing data, and keeping track of important dates. All of these features are crucial to a productive revenue-generating organization.
Amy: In credentialing there are thousands of data points. It’s so complex, there are so many little pieces. The vastness of credentialing presents challenges for practices choosing to build themselves or track data manually.
Amy: We offer 43 different services, encompassing the credentialing process to our clients. Those services include what we refer to as “Internal Credentialing.” When a facility or group vets out their new providers and assesses, “Are they really who they say they are? Are they a high-quality provider?”If so, the group is comfortable bringing that provider into their practice knowing they went through a stringent internal credentialing process. Other services we offer are around the hospital affiliation or privileging process. We assist in getting providers affiliated with hospitals and physician groups so they can admit and see patients. We also provide licensing and all that entails — a provider’s state license, DEA, controlled substance permits. The last piece and potentially the biggest one is payer enrollment — the process of getting providers enrolled with insurance companies.
Rachel: Consulting is a newer service that we’ve been offering to providers who want to start their own business and don’t know where to start. In a recent consulting session, one of our clients had five brand-new credentialing specialists that have never worked in healthcare that we were able to train on the basics of credentialing. So it’s really just teaching folks the bare bones of credentialing, whatever questions they may have, and giving them more resources.
Amy: Enhancing organizational efficiency is a significant opportunity we address for our clients.
Rachel: The biggest challenge is how to keep all of that data organized. Clients come to us with data across several spreadsheets that need to be organized into one place. Also, many don’t have all the data required and need our assistance in gathering any gaps in information.
Amy: Revenue is another big challenge. Inaccurate credentialing and an inefficient process can result in lost revenue to the tune of hundreds of thousands, if not millions, of dollars. Many clients come to us pretty frantic that every day they’re losing money. Other times, their credentialing has passed through a few different credentialing companies, so their data is muddled and not very accurate, which also leads to revenue issues. These are all challenges Modio can help with and make the credentialing process much more seamless and accurate.
Amy: Investigating state and commercial payer processes, as these can vary by state.
Rachel: Agreed, it’s similar with licensing, understanding licensing boards, i.e., which board needs what for which state – it’s a lot of information.
Amy: The research that it takes to understand what you need to physically get started with the licensing process. What you need, how to do it, and so forth is extremely time-consuming. Also, the licensing applications themselves can be very detailed. They can request a lot of information. An application can take 10 minutes or it can take a couple of hours. Our team can handle the application process, giving that time back to a group or provider.
Rachel: A lot of the state applications are really lengthy and require a lot of data.
Amy: Knowledge, experience, and attention to detail. And communication. If you’re early on in the process, trying to talk to a CVO and engage with them and they’re lagging in their response time to you or they’re not being very communicative, that’s a red flag of what’s to come.
Rachel: Also, transparency in reporting and transparency in where they’re at in the process. For example, when was an application sent out, and how often are they following up with a payer or state licensing board?
Rachel: The service, the personal touch, and the software is huge — the software to keep it all organized, as we keep saying over and over.
Amy: Also, our turnaround times are better than industry standard. We’re averaging 58 business days for payer enrollment, and the industry standard is about 90. Furthermore, our team upholds a standard of timely responses to our clients.
Amy: I love building relationships, and I love interacting with the clients and helping them feel better about their work. In many instances, they come to us in dire need of help. The result may not be immediate, but we are helping them every step of the way, and eventually they’re going to achieve the goal they want. That’s a good feeling — I love that! I like interacting with people and helping our clients.
Rachel: When you can take a client who is losing money, or they have $500,000 in outstanding claims, and you’re able to get in and help them get organized, get their providers enrolled, and enable them to start making money off the services their providers are doing, that feels really good. Being able to complete the tasks they’ve asked us to do and show them all the work we’ve done and the value our services provide to them, that’s a lot of fun!
Amy: We’re also ultimately helping the patient. That’s always our end goal to provide excellent care and services, and it all kind of ties in together. The ultimate bottom line is patient care. And if you’re trying to enroll a nephrologist, and they don’t have any in that area, it’s a good feeling when you finally get that nephrologist enrolled so they can help that population.
Rachel: We’ve all been a patient at one point in time, trying to navigate our own insurance and making sure our providers are in network. When you think of it from that angle, we can all relate to how frustrating it is if it’s not going right and how nice it is when everything goes smoothly.