Q&A: The Importance of Utilizing Key Performance Indicators (KPIs) in Provider Enrollment

Allyson Schiff discusses the importance of utilizing robust Key Performance Indicators (KPIs) to improve your provider enrollment department’s performance.

Q. Why does provider enrollment performance matter?

A. Provider enrollment has a significant impact on provider satisfaction, brand integrity, and a healthcare organization’s bottom line. Any delay or impediment to successful and efficient provider enrollment equates to frustrated providers and lost revenue. Every month enrollment is delayed, healthcare organizations lose an average of $100,000 for a single primary care provider and $300,000 for a single specialist.

Inefficient provider enrollment leads to claim denials—a major source of revenue leaks. When a provider is not properly enrolled with a health plan, his or her encounters will be written off. If providers see patients before they’re enrolled in a health plan, that claim can be denied, resulting in a surprise bill to the patient. Similarly, when healthcare providers are not enrolled properly with one or more health plans, or if they have accidentally allowed their enrollment status to lapse (by missing a reenrollment deadline), billing disruption is inevitable. An otherwise clean claim submitted for services will either be denied by the health plan or covered at out-of-network rates. Any of these scenarios leads to write-offs, bad debt, and both patient and provider dissatisfaction.

Q. Why are KPIs important?

A. Tracking KPIs helps you improve your department’s performance by identifying bottlenecks throughout the enrollment process. In 2017, healthcare organizations wrote off 90 percent more claim denials (the equivalent of a $3.5 million loss over four years for a 350-bed hospital), compared to 2011. Monitoring provider enrollment performance is critical to improving your organization’s bottom line.

Q. Which KPIs should you track?

A. Identify the key tasks and metrics in your provider enrollment department that you want to track, trend, and report on. Some examples include:

1. Days In Enrollment (DIE). The DIE tracks your department’s and payer’s performance. The formula for calculating DIE is: Total number of elapsed days from the time you submit an enrollment request to a payer, compared to a standard/contracted turn around time (e.g., 90 days). If the total number of elapsed days is 120, you know the payer is not performing well. If the total number of elapsed days is 45, you know the payer is performing better than the average.

2. Department Processing Times. How long does it take your staff to obtain and enter provider data and documentation into their software system, CAQH, PECOS, and onto payer applications?

3. Provider Processing Times (i.e., days in signature stage) – How long does it take for your providers to collect required documentation, sign their signature packets, and get them back to your department?

4. In-Process Charges – What are the gross charges that are associated with your in-process applications? Can you break this down by healthcare organization, hospital, clinic, provider, payer?

5. Quality. What quality metrics should your staff use when updating their payer follow-up notes? How often are they documenting when and with which payer representative they spoke? What is the next action step that they need to take to obtain the PIN?

6. Number of applications denied or returned. When provider enrollment is done manually, errors are common, causing application delays and denials. The number of applications health plans place in development or reject for additional documentation or verification, or due to other common errors, is an important indicator of provider enrollment performance.

7. Enrollment Claim Denial Percentage. How many claims are denied due to enrollment issues? To fully appreciate the impact of provider enrollment on your organization’s bottom line, you must quantify lost dollars. To do this, track denial codes to quantify how much revenue (reimbursement) is lost when encounters are written off. For a true, big-picture view, you should track information over a period of time (quarterly, semiannually, and annually). Examine the denial reason codes to identify denials that are due to provider enrollment issues. Do some departments have more enrollment-related claim denials? Use this information to take steps to correct enrollment problems.

8. Provider participation status. Reconcile payer data to identify providers who are not enrolled in health plans, taking care to ensure that all locations where providers are seeing patients are registered with the health plans. Your goal should be to ensure that all eligible providers are enrolled at their respective billable locations prior to seeing patients. Take the necessary steps to enroll the providers who are non-participating in each health plan.

Q. Once you identify the KPIs you want to track, how do you begin to track them?

A. The easiest way is through technology. Check to see if your provider enrollment software will allow you to track and report on the specific steps involved with provider enrollment. If your provider enrollment software does not allow you to track, age, or quantify these KPIs, begin to track them manually. The goal is to establish provider enrollment performance baselines, identify bottlenecks throughout the process, and then take corrective action to improve overall performance.

TractManager’s technology-enabled Provider Enrollment solution tailors enterprise-wide KPI and benchmark reporting to quantify and monetize enrollment opportunities. Our Provider Enrollment solution can help your provider enrollment department improve its performance. By partnering with our enrollment experts, Cooper University Health Care reduced its enrollment-related claim edits by 90% and generated $1.5 million in incremental revenue within two years.

For more information on accelerating your provider onboarding processes, download The 4 Ds of Provider Onboarding Guide.

Author:

Allyson Schiff

Senior Director, Strategy & Growth, Provider Management

Allyson Schiff joined Newport Credentialing Solutions in 2009 and joined TractManager when Newport was acquired in 2018.

 

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