We recently asked Dina for her insight on contracting and credentialing. Here’s what she shared:
Can you tell us the story behind your Sonoma Credentialing Services?
In 2011, during my 11-year payer contracting and credentialing career with a large, national respiratory durable medical equipment and pharmacy company, I realized that my knowledge was so specialized that I could apply it to fulfill a unique niche in the healthcare industry. After great thought, in 2012 I decided to leave that company and start my own consulting business.
Since then, I’ve spent the past five years helping a variety of large and small healthcare organizations and providers with governmental and private payer contracting and management. In addition, I’ve had the honor of being asked to help create and present numerous live webinars and presentations, and write online articles on the topic of payer enrollment, contracting and credentialing processes, and best practices. It’s been an amazing to experience!
What do you feel differentiates your service and sets you apart?
Each organization is different in what they are looking for in an outsourced solution. I believe my success comes from fulfilling a unique niche by providing an individual, highly personalized and skilled service that some larger credentialing organizations might struggle with. In speaking with potential clients, I frequently hear that they are unhappy with their current outsourced solution because of poor service and broken promises. When it comes to payer contracting, specific outcomes cannot be guaranteed for every provider type and specialty, so I always communicate honestly and am upfront prior to any engagement. Providers appreciate that.
Can you talk a little bit about the complexity of insurance payer management, contracting and credentialing? What challenges are your clients facing in these areas?
Insurance payer management is an obscure web of processes that enables providers to request becoming in-network with health plans so they can be reimbursed for services provided to patients. Once contracted with a payer, providers are required to maintain their billing privileges through the process of re-credentialing. Timeframes vary by payer and provider type, but re-credentialing is typically every one to three years.
Adding to this complexity, there are many types of payers. For example, there are governmental (state and federal) and private (commercial) payers. There are also private payers that manage governmental insurance programs (like Medicare, Medicaid and the ACA/Marketplace Exchange). Some payers even manage certain provider types for other payers. There are also third-party networks that contract with payers who providers can contract with – some for a fee. Each payer and network has its own set of policies, forms, requirements and processing timeframes. Putting together the pieces of each payer’s puzzle can be confusing but also rewarding!
One of the biggest challenges facing my clients today is closed or narrow networks. These days providers cannot rely on “meat and potatoes” revenue such as Medicare reimbursements like they did 15-20 years ago. With reimbursement cuts on every corner, they need market influence by being able to say “yes, I can take your insurance” to each patient, so network expansion is critical to most providers. When providers are not in network, recouping payment can very difficult and can mean the patient is ultimately referred to an in-network only provider, which creates more due diligence for providers and less options for patients.
In addition, the healthcare industry never rests – its landscape is constantly changing, evolving and devolving as we see more mergers, acquisitions and consolidations within health systems and payers. These complexities translate into new challenges for providers to keep up with.
Last but not least, reimbursements are declining while strict regulations, extreme patient documentation, and lengthy prepayment audits are suffocating providers. Patients are faced with high deductibles, skyrocketing premiums, higher pharma costs and fewer choices. The challenges that my clients are facing follow this trend – they need to do more with less. That is why they reach out for help.
How has payer management, contracting and credentialing evolved since you started your business? What are the major changes you’re observing today?
Since beginning my career in 2001, the biggest changes I’ve experienced have been from HIPAA and technology. When I began, there were no NPI numbers. In 2005, I developed from scratch a complete system for creating and managing over 300 brand new NPI numbers, as well as helping complete new EDI agreements for each payer for NPI number – all with different service location addresses and some with different tax ID numbers and names – so that my company could comply when billing payers electronically.
Over the past 16 years, technology has created efficiencies that have literally transformed my work. For example, credentialing applications that were once completed by hand or typed can now be can completed by using secure payer web portals, Adobe Acrobat Pro and credentialing software products. Documents that were paper-based and stored in file cabinets can be stored by a wide variety of cloud-based document management tools to choose from. Back then there were no e-faxes – faxing was done with an actual fax machine! And back then getting provider signatures meant wet-ink only because eSignatures did not largely exist. Additionally, I’ve seen web conferencing and desktop sharing tools revolutionize the way we meet with payers and providers.
Today we’re seeing a more paperless credentialing environment, which is good for my business because that means that some payers accept applications and documentation electronically rather than sending originals via mail. We’re also able to access more real-time information, which is useful in tracking application processing.
However, these changes have not been without challenges. As payer costs and budget cuts increase, they are also having to do more with less. For example, payers are now automating their provider relations interactions which means less staffing, more complex phone trees, longer phone wait times, and more payers only accepting email as communication rather than phone assistance. I’ve also seen a shift toward a more complex credentialing process with tighter regulations and restrictions, increasing application fees, longer processing times by payers, more provider competition for payer networks, and less options for providers.
What can providers do to make the credentialing process go faster?
This depends on who the provider has handling their credentialing. For providers who are open to it, outsourcing can be a sensible way to leverage the specialized knowledge, experience and industry connections that help the payer credentialing process flow smoother, more timely and successfully.
For providers who prefer to keep credentialing in-house, significant delays can occur from not having the right person manage these processes. Delays can be caused by not knowing each payer’s processes, not having sufficient knowledge, having multiple people handling different steps, having to train someone to help, not keeping track, not following up. These factors can cause delayed or lost revenue. Depending on the provider, I might suggest using a credentialing software solution to help track and manage credentialing and license expirables, to house provider information and documentation, and to help complete and track enrollments and contract information and documentation. There are a variety of affordable, simple and easy-to-use cloud-based solutions that require minimal technology and can fit a variety of budgets.
How has the Affordable Care Act affected your business?
With the ACA, there are many more health plans/payers that are state and regionally based for providers to contract with. Providers are needing to be contracted with these payers so they can meet the increased demand due to higher member enrollment. But many payers are not as open to adding new providers of certain types and specialties. For example, some of my clients have patients who are covered under federal marketplace plans but they are not able to accept them because they are not in network with that plan. In some cases, if providers cannot become contracted, they can end up having to turn those patients away even if the patient prefers to go to that providers, which can be frustrating on both parts.
What headlines or trends in the world of revenue cycle management are you following today? Why do they interest you?
To keep current with my industry and clients, I follow news and trends on topics such as payer and health system mergers and acquisitions, single payer forecasts, contracting and credentialing, the DME/HME, telehealth and home health industries, and competitive bidding in Medicare by subscribing to trade publications and websites related to payer contracting and credentialing. I also belong to a variety of related groups on LinkedIn to receive industry updates and news. I’m also a member of NAMSS, which keeps me connected to the latest in credentialing news, education and trends.
What’s one piece of advice you find yourself repeating to clients over and over?
I always advise my clients to start early on the payer contracting and credentialing process, to get all of their licensing and documentation in order before starting the application process to payers, and to expect payer processing timelines to take twice as long as anticipated.
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