Building a Robust Provider Enrollment Strategy: A Definitive Guide

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A Guide to Provider Enrollment
Building a Successful Provider Enrollment Program
A Webinar Presented By Cati Harris, CBCS, CCS,
CPCS Director of Provider Credentialing - Solor,
Inc
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Cati Harris, CBCS, CPCS
Director of Provider Credentialing Contracting
Solor, Inc.

• Professional Experience
• Over 20 years experience in Medical Billing,
  Coding, Provider Credentialing/Contracting
• 15 years clinical experience
• Currently provide credentialing services for 2
  major hospital systems, and 14 private practices
  (35 physicians/PA/NP)
• Educational Experience
• Diploma with Honors in Medical Billing Coding
• Certified Billing and Coding Specialist
• Certified Provider Credentialing Specialist
• Certified Credentialing Specialist

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Learning Objectives

• Welcome to the Webinar!
• This webinar was developed to provide you with
  information on building your credentialing
  program with focus on the preparation,
  verification, submission, and completion of the
  provider credentialing process.
• When to Start Credentialing
• Setup and Maintenance of NPPES, IA Management
  System, CAQH, PECOS
• How to review, validate, and track provider
  documents
• How to Prepare, Review, Submit, and Track Payer
  applications
• Items to complete once the provider is
  credentialed/contracted
• Linking of a previously credentialed provider
  with payers to your tax id/contracts
• Brief overview of Provider Revalidations

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Keys to Success in Credentialing

• Research
• Preparation
• Tracking
• Communication

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RESEARCH
Research is the key to SUCCESSFUL Provider
Credentialing

• The research process is divided into two parts
• Provider Research
• Payer Research

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First Step - Provider Research Questions

• What is the providers anticipated start date?
• Is the provider newly licensed?
• State Approved Medical License
• Does the provider have a registered NPI?
• Has the provider been previously credentialed
  with payers?
• Does the provider have any disciplinary actions,
  previous criminal charges, or malpractice claims?
• Mid-Level - Is the supervising md approved?
• Mid-Level - Is the collaborative agreement signed?

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Research - Payer

• Payer Application and Document Requirements
• Copy of Application and Applicable Forms
• Online Payer Application Location
• Payer Estimated Processing Time
• Payer Preferred Submission Method
• Payer Contact Information
• Website, Email, Phone, Fax
• Payer Provider Representative Contact Information

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Provider Document Preparation

• Review All Documents for Accuracy, Dates,
  Infractions
• Verify Licensure and Board Certifications are
  current with no infractions - Explain previous
  disciplinary actions
• Verify Malpractice Insurance is for current group
  and review for previous claims
• Previous Malpractice Claims - Provider must
  provide detailed information/explanation
• Verify DEA License is Current without restriction
• Verify Provider Education, Residency, Fellowship
  etc.
• Create a Provider File
• This file will contain all original documents.
• It is suggested to save a copy of the originals
  in a secure location on your computer.
• Organization of the Provider File (Two Sided
  Folder)
• Access Provider Logins
• CAQH, PECOS, IA, NPPES (I/A, PECOS - Prefer
  Surrogate Access)
• Attest CAQH every 60 days (120 days is
  requirement)

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NPPES

• NPPES - https//nppes.cms.hhs.gov//
• Obtain Login/PW or Setup access (The login for
  the IA System is the same for NPPES)
• Verify Provider Information
• Correspondence Address and Practice Address
• Provider Contact Information
• Phone number, Email
• Taxonomy
• Delegated Access
• Provider IDs
• NPPES Must be current and approved before
  proceeding with any provider credentialing.
• Print out any update confirmations completed

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CAQH

• CAQH - https//proview.caqh.org/Login/Index?Return
  Url2f
• Obtain Login/PW or Setup access
• Review/Complete each section
• Add your information in the credentialing contact
• Add your email on the provider info page as a
  secondary contact
• Ensure the Authorization Section is Checked to
  Allow all Payer Access
• Upload the following documents
• Attestation
• Certificate of Insurance
• State License
• DEA
• Provider CV
• Board Certification
• Med School Degree including any Residency or
  Fellowship Cert

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PECOS

• PECOS - https//pecos.cms.hhs.gov/pecos/login.doh
  eadingLv1
• The login for PECOS is the same username and
  password used for IA Management System
• Prefer Access via Surrogate
• Select My Associates
• Scroll to bottom and check for current
  enrollments
• If provider is currently enrolled, check to see
  if the provider is enrolled with the correct
  state and MAC.
• If provider is not enrolled, you will select to
  start the process.
• Complete all tabs, run an error check, locate
  name of group authorized signatory for the
  reassignment of benefits
• Once error check shows no errors, you can
  complete submission
• Be sure to print out copy of application and
  submission
• You will receive email confirmation
• Re-Validations
• Select revalidation notification center instead
  of My Associates

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Application Preparation

• Completion of the payer application with current
  and accurate information is critical to the
  provider enrollment process.
• Errors on the application or within the
  application package can result in holds or
  rejections
• Complete all fields on application. Do not leave
  any blanks.
• If the information does not apply enter N/A in
  the space.
• Do not write to refer to another document in the
  space.
• Review document a min of 2 times
• Once doing a forward review
• Once doing a reverse review

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Linking a Provider already PAR with the PAYER

• If the Provider is already credentialed/contracted
  with the payer as a participating (PAR)
  provider, you will need to complete a link to
  your TAX ID and group contract.
• To Complete a link
• Complete the Provider Link Letter
• Include the Tax ID, Group NPI, Practice Address,
  Phone, Fax
• Include the provider/mid-levels Name, Individual
  NPI
• Include the effective date of the link
• Include a current W9 for the group
• Once you have completed the above information,
  you will submit the link letter via the preferred
  method for the payer. Most payers have a specific
  email or fax they want the request submitted to.
  Make a call to the payer to ensure the specific
  method of transmission of the link letter.
• Exception Medicare/Medicaid - For Medicare you
  will complete the reassignment of benefits in
  PECOS by submitting a change of information
  application under the current enrollment.
  Medicaid varies by state, contact your local
  Medicaid enrollment office for directions

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Provider Re-Validation

• All Payers require re-credentialing/re-validation
  once the provider is credentialed.
• Important Information Regarding Provider
  Re-Validations/Re-Credentialing
• When the provider is initially credentialed,
  inquire with payer when the re-credentialing will
  be due.
• Most payers are either every 3 years or Every 5
  years
• Maintain a database or spreadsheet for each
  provider with the payers re-validation dates
  listed.
• At least 60 days prior to re-validation due date,
  inquire with the payer the requirements for the
  providers re-validation
• Ensure CAQH is up to date and attested prior to
  inquiring or beginning re-validations.
• PECOS aka Medicare Re-validations are every 5
  years
• Select revalidation notification center instead
  of My Associates within PECOS to obtain due
  date of re-validation and to complete the process.

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Termination of a Provider

• In the course of business, there may come a time
  in which a provider is terminated from your
  practice, whether it be voluntary or involuntary.
  When this takes place, there are steps you need
  to complete as the group to ensure the provider
  is no longer linked to your tax id and group
  contract with the payer.
• Prepare the Letter Requesting a Provider
  Termination.
• Include the Tax ID, Group NPI, Practice Address,
  Phone, Fax
• Include the provider/mid-levels Name, Individual
  NPI
• Include the effective date of the termination
• Include specific language that requests the
  provider be removed from your group contract and
  unlinked from your Tax ID with the payer.
• After you submit the letter, follow up within 72
  hours of submission to ensure receipt and
  processing of the termination.
• Exception Medicare/Medicaid - This will be done
  in the providers PECOS by removing the
  reassignment of benefits to your practice and
  updating the contact information. This can be
  done by the provider. Request proof of completion
  and approval from the provider. For Medicaid,
  contact Medicaid for yoru state directly and
  follow the process.

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Provider Enrollment Tracking is the foremost
action to ensure timely, efficient submission and
processing of the provider enrollment application
package.
Tracking

• Lack of tracking can lead to
• Payer misplacing application package
• Delayed application submission and processing
• Missed request for more information, missing
  documentation
• Application being Red Flagged by Payer
• Financial loss and increased credentialing costs

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Provider Document Tracking

• .
• DOCUMENT TRACKING TOOLS
• Provider Document Checklist
• Excel Tracking Spreadsheet

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Communication

• Communication is the key to successful and timely
  processing of your providers credentialing
  application.
• Keys to successful communication
• Consistent updates provided to the provider and
  appropriate administrative staff via live google
  doc links and/or Emails
• Consistent tracking and follow up on the status
  of the submitted payer applications.
• Tracking the payer provided estimated processing
  times.
• Updating/Maintaining Tracking Tools

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Steps to Minimize Financial Impact

• Begin the credentialing process a minimum of 60
  days before provider anticipated start date.
  Preferably 90 days.
• Maintain CAQH and attest every 120 days
• Ensure IA, NPPES login stay up to date with
  accurate information.
• Consistently follow up with payers to ensure
  timely processing.
• Organize and maintain all provider data,
  documents, and applications. Update frequently.
• Timely Provider and administrative staff
  credentialing status updates.
• Maintain Live Update Document (Google Sheet, One
  Drive, MS Teams, Etc)
• Maintain tracking spreadsheet for provider payer
  applications submissions and updates.
• For Mid-Levels - Research billing Incident Too

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Provider Credentialing is Approved..

• What is next?
• Request copy of approval/welcome letter from
  payer
• Request payer specific provider
• Inquire when the revalidation will be due
• Request copy of contract and fee schedule
• Review both the contract and fee schedule prior
  to signing
• Once signed, request copy of signed contract
• Create Master Information Sheet with payer
  specific information
• Credentialing effective date
• Payer Specific Provider
• Contract Effective Date
• Fee Schedule Effective Date

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Information Storage

• Once you have the requested payer approval
  information, you will need to store a physical
  and digital copy.
• Create a Provider Binder
• Section for each Provider
• Within Each Provider Sections, Organize by Payer
• Payer Section includes
• Provider Information Sheet
• Payer Welcome/Approval Letter
• E?ective Date, Revalidation Date
• Payer Specific Provider
• Copy of Contract/Fee Schedule
• Original Submission Package

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Forms

• Included with this webinar are several forms
  mentioned throughout the presentation
• Credentialing Description of Services
• Provider Enrollment Information, CV Requirements,
  Document Checklist
• CAQH Attestation Form
• Cover Letter, Fax Cover Letter for Payer
  Application Submissions
• Cover Letter, Fax Cover Letter, and Provider Link
  Letter
• Verification of Licensure/Certification/Education
  Form
• Tracking Spreadsheet
• Payer Application Information Form
• Termination Letter
• If you did not receive the forms with this
  presentation, please reach out to me via email
  cballard_at_mysolor.com

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If you answered YES, please contact me to
arrange your FREE consultation for credentialing
services.
Are you in need of an experienced credentialing
professional?
Mention Code WEBINAR to Receive a discount on
contracted services!
Cati Harris, CBCS, Director of Provider
Credentialing Solor, Inc Phone
704-675-7279 Email cballard_at_mysolor.com
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Questions?
Cati Harris, CBCS, Director of Provider
Credentialing Solor, Inc Phone
704-675-7279 Email cballard_at_mysolor.com Thank
you for your time and attendance!
Register Now