The Most Important Provider Enrollment Regulations

The Most Important Provider Enrollment Regulations

On March 2011, new requirements for the HCA (Health Care Authority) were implemented by the Affordable Care Act. These requirements include additional screening requirements for referring providers, disclosures, application fees, and re-credentialing for all providers every five years.

The HCA collects application fee according to the federal rule ($352) from providers before executing the provider agreement. There are some providers, who are exempt from these fees:
• Providers that have paid fees to Medicaid
• Individual providers
• Providers that enrolled under Medicare

Re-enrollment is necessary for all physicians who want to treat patients and have privileges. Re-credentialing includes filling up the application form, attaching all documentation (with updated information), and paying application fee. You'll get a receipt that will mean the beginning of re-credentialing process.

Provider Enrollment on the Portal, or PEP, helps complete the application more thoroughly and carefully and guides you through the entire credentialing process. It has an online application form, where PEP automatically populates identical data field, which shortens the time to finish the applications and refuses errors and mistakes. Besides, it doesn't allow you to submit the application before you fill out all required information. If your information is not consistent, your application will be denied. Before, you had to sign the application yourself, but now with an E-signature feature, you can sign the application online. You can also correct information online, which wasn't possible before. You have 30 days to change information if needed. And one of the most important features is tracking. In the past, providers had to call to the credential manager to find out something about the application. Today, you can receive updates to the e-mail.

There are also new disclosure requirements. Now, HCA is required to collect data about controlling interests of providers, disclosures of ownership, managing employees and helping providers during credentialing process and re-credentialing process. All disclosures should include the name, social security number, and date of birth of the disclosed providers. Everything is collected in the Disclosure Statement and in the HCA's Provider one online application system.

All health care facilities have to complete a financial report presented by an individual accountant of the facility. All documents, notes and schedules as required by the American Institute of Certified Public Accountants should be presented in the report.

If the facility doesn't prepare the report, it should at least provide a statement of revenue, statement of cash flows, changes in earning, and balance sheet. Sometimes audited statements can be in a consolidated format, and may not be audited.

HCA may obtain and use your medical information. It can collect information about you in many different ways. For instance, HCA can get your data when you apply for payment, enroll in UMP, call Customer Service, send claims, or submit appeals or complain. This information can be related to medical care or some general data.

HCA is required to keep this information confidential. It doesn't disclose it to the third parties and can't give it to the providers.

Premier Credentialing Solutions, LLC has the best credentialing and licensing solutions for you and your business; We proudly offer Provider Enrollment & Physician Credentialing, Medicare – Provider Enrollment & Revalidation, Medical Licensure Services, and Full-Service Credentialing For Billers / Billing Companies. Call (800) 455-4773 for a free, no-obligation consultation.

©  Premier Credentialing Solutions, LLC.  An Illinois-Registered LLC.  2017.  All Rights Reserved.

How to Submit Credentialing Documents?

How to Submit Credentialing Documents?

To start the credentialing process you should submit an application. Whether it's a hospital, medical board, locum tenens organization, or an employer, they all have special forms to keep information organized. Your files are checked, reviewed and verified (including NPDB, DEA, OIG and background checks) for accuracy by an assigned coordinator. These coordinators have to collect supporting documents from you, check them, verify the authenticity of information, and prepare files for monthly credentials committee meetings.

A standard Credentialing Committee consists of ten practitioners representing all specialties at a facility. They usually meet once a month to review and discuss files prepared by coordinators. The Committee will either approve or decline your application based on information you provided there. For this reason, it's important to remember that everything you provide in an application will be thoroughly checked. Verifying is the most important part of credentialing.

The requirements for credentialing are constantly changing, and documentations that were not required in the past can play a vital role today or soon will be important. You should scan copies of the supporting documents into image files so they can be quickly transmitted electronically. There are several states (Like Texas), where one standard Credentialing Application is used by all healthcare facilities, and you can usually get it with hospital-specific addendums. Keep all copies of your applications, it will allow you to refer to them and keep records if questions arise. Before filling an application, prepare all important data of your practice history. Don't forget to list all State Licenses you've held, all hospitals you've had privileges, details of malpractice claims (if any), Board Certification dates and disciplinary actions. If the Committee finds out something that wasn't mentioned in your application, it is a red flag and could result in denial of the application. Then, many coordinators report denials to the National Practitioner Data Bank, and it will bring more problems to you.

CV can also be an important part of your credentialing process. There is only one thing to remember about the CV: it should go in chronological progression and have start and end dates. Some providers write only years (like the years in residency, medical school, etc.), but coordinators need your history with dates, as you're required to explain any time gap longer than a month.

Re-application is a long and money-consuming process, so make sure nothing is missing before sending the application. The vast majority of the facilities use the CAQH, or the Council for Affordable Quality Healthcare, to coordinate all information needed for credentialing. If you have never used CAQH, you will have to create your profile and then constantly update your information there. Be sure to carefully choose your specialty in CAQH, because your choice will affect the way claims are paid and proceed and determine whether you can be designated as a primary care specialist.

After everything is sent, you have to be really patient - credentialing process takes a lot of time since your complete history should be verified. Sometimes, credentialing coordinators can estimate the time they need to make a decision. On average, it takes 90 days or longer.

Premier Credentialing Solutions, LLC has the best credentialing and licensing solutions for you and your business; We proudly offer Provider Enrollment & Physician Credentialing, Medicare – Provider Enrollment & Revalidation, Medical Licensure Services, and Full-Service Credentialing For Billers / Billing Companies. Call (800) 455-4773 for a free, no-obligation consultation.

©  Premier Credentialing Solutions, LLC.  An Illinois-Registered LLC.  2017.  All Rights Reserved.

The Process of Physician Credentialing

The Process of Physician Credentialing

Credentialing is a system that establishes contacts between health plans and providers. However, it's riddled with redundancy, and many organizations collect identical information. An average physician spends at least 3 hours every year to submit 18 credentialing forms, and staff spends over 20 hours reviewing them. If you're not going to work in cash-only medical practice, you will have to go through a credentialing process. However, you can handle your part more efficiently. Follow the steps below not to get mired in this process.

Start well in advance

The credential process is not among quick ones. When a new physician is joining the team, you should plan everything months in advance. The same applies if you're a newly recruit associate. The problem can appear when many organizations start asking for the same documents needed for the credentialing process. With that in mind, don't be surprised that it takes weeks to process all paperwork, so if you overlook any request for information, it may cause financial problems, since you can't bill for your services. So, it's important to tie the start date of a new physician to the successful signing of all key documents. Even if you don't want to bother yourself with this and outsource credentialing to somebody else, this person should be able to travel to the physician’s home to get a copy of another document, or escorting a physician to the bank and have all documents notarized, if that's required.

A sustainable process is a key to success

It's understandable that the initial submission of all documents leaves people exhausted, but you still have to make sure everything goes smoothly and you know where all your documents are. Re-credentialing is always somewhere around the corner. There are two main options for handling the workflow, and they depend on the amount of money, time and staff you have (or don't have). You can create a spreadsheet of hospitals, payers and third parties and record there all submissions and deadlines. You can assign an employee to keep all forms signed and updated. Another option is to lease (or purchase) a credentialing software or outsource the entire process to one of the vendors that specialize in this field. Whatever you choose, you should always monitor the process.

Learn about the most important success factors

There are special credential databases, such as CAQH Universal Provider Data source, that won't let you leave any field in the form blank. Remember that with a small detail missing in the form may be rejected. One decision can take several months, so take time to complete every element, and attach all necessary documentation. And don't even try to estimate start and end dates or other data from memory.

Decide what steps you can take in the interim

Some people believe that it's fine to bill under other identification while waiting for the decision of the credentialing process. In fact, this can lead you to serious legal problems if an adverse event happens - the name of the rendering physician won't be the same as the name listens on the medical claims. Besides, some health plans strictly prohibit this protocol of billing under another physician. One of the most common ideas physicians have is to use a -Q6 modifier and bill a physician as a locum tenens. But the best thing you can do here is to learn what is required for credentialing and follow all instructions precisely.

A helpful indicator of a properly running credential process is the record of denials and adjustments that are taken during the billing process. Keep track of the claims denied and the accounts written off, because of incomplete credentialing.

Premier Credentialing Solutions, LLC has the best credentialing and licensing solutions for you and your business; We proudly offer Provider Enrollment & Physician Credentialing, Medicare – Provider Enrollment & Revalidation, Medical Licensure Services, and Full-Service Credentialing For Billers / Billing Companies. Call (800) 455-4773 for a free, no-obligation consultation.

©  Premier Credentialing Solutions, LLC.  An Illinois-Registered LLC.  2017.  All Rights Reserved.