Managed Medicaid: The nightmare within

Written by Allyson Schiff, Vice President of Operations, Newport Credentialing Solutions

In honor of Halloween, Newport Credentialing Solutions’ Vice President of Operations, Allyson Schiff, spotlights a nightmarish Medicaid situation which providers throughout the country are being forced to live.

Earlier this year a mandate was introduced requiring providers to complete state-specific regulated Medicaid enrollment before they can enroll in Managed Medicaid plans. Failure to enroll in state regulated Medicaid plans means a provider is unable to proceed with Managed Medicaid plan enrollment. While the mandate seems simple, there is hidden horror in this situation. It can take months for a provider to get enrolled in a state Medicaid plan; and many times they can’t begin the application process for Managed Medicaid enrollment until after state Medicaid enrollment is complete. This translates to months of delays before a provider can see patients and get paid. And the nightmare doesn’t stop here. For providers who work across state lines the horror is multiplied as they must be enrolled in each state’s Medicaid plan before they can move forward with their respective Managed Medicaid applications.

Established providers that have been grandfathered into Managed Medicaid plans for years but have chosen not to participate in state Medicaid are also faced with a gruesome reality. Either they enroll in state Medicaid or risk of being pushed out of their existing Managed Medicaid plans which may, in turn, result in loss of established patients.

While all sounds doom and gloom, there are some things that can be done to minimize the pain of this wicked situation.

1) Get enrollment started with state-specific Medicaid enrollment as quickly as possible to avoid needless processing delays. When onboarding, immediately after a provider signs a contract with a hospital, large health system, or physician group start the Medicaid process.

2) Talk with your contacts at Managed Medicaid to learn about your options as quickly as possible. Ask for leeway. Some plans may be willing to work with you if they know the enrollment process for state Medicaid is underway.

3) Put a reliable process in place to manage provider enrollment. Cloud-based enrollment software that streamlines Medicaid follow-up can literally become a lifesaver. Automated alerts let staff know the minute a state Medicaid enrollment is complete so they can immediately begin the Managed Medicaid application. Otherwise staff are left to wait for Medicaid approval to come through snail mail or they must be very diligent with repeated calls for approval status. This manual process can easily add two months to the approval process.

There is no escaping the new Managed Medicaid mandate. For those who don’t take it seriously, the nightmare will become reality. Patients, some of whom may have been in existence for decades, may find their participating providers have been dropped out of network. When patient volume is lost, so too is revenue, which leads to consequences too horrifying to consider. Being prepared, with cloud-based enrollment software will end the nightmare before it begins.

Payer Enrollment Case Study

A 36-facility Medical Group in metropolitan New York had trouble identifying which medical providers were enrolled with its 44 health insurers. Read this case study to how Newport Credentialing Solutions reduced denied claims by 55% and improved enrollment by 125%.

New York Presbyterian Hospital

New York Presbyterian Hospital (NYP), with five acute-care facilities and multiple clinics throughout New York, had outgrown its payer enrollment process. Learn how Newport Credentialing Solutions improved credentialing staff productivity by 10x.

Why physician billing holds the key to preventing hospital closures

According to the American Hospital Association, hospitals are closing at a rate of about 30 a year. A recent Bloomberg article predicts the pace of closures to accelerate over the next 18 months.

In August, Knoxville, Tenn.-based Curae Health and its three hospitals in Mississippi filed for Chapter 11 bankruptcy. In July Rockdale, Texas-based Little River Healthcare, its parent company and several of its affiliated entities entered Chapter 11 bankruptcy. In May, Arizona-based Gilbert and Florence Hospitals at Anthem entered Chapter 11 bankruptcy. The list goes on.

Bloomberg goes on to quote Morgan Stanley analysts who looked at data from roughly 6,000 U.S. private and public hospitals and concluded eight percent are at risk of closing; another 10 percent are considered “weak.” The firm defined weak hospitals based on criteria for margins for earnings before interest and other items, occupancy and revenue. The “at risk” group was defined by capital expenditures and efficiency, among others.

This uncertainty within the healthcare industry has hospitals and health systems seeking new ways to generate revenue. For many, the answer is hiding in plain sight; their physicians and allied health providers.

Doctors are the lifeblood of a hospital. They directly impact patient outcomes and patient experiences. They are also the primary source of a hospital’s revenue – or they should be. On average, a physician or surgeon generates $1.56 million annually for their affiliated hospitals. If a physician isn’t billing to their fullest potential, serious revenue may be lost.

A hospital’s complex economic environment elevates the importance of getting—and keeping—physicians and surgeons billing to stabilize revenue. Here are four ways that physicians and surgeons can improve margins.

Don’t overlook the importance of contract management. Hospitals are contract heavy. In fact, it isn’t uncommon for a large hospital to have tens of thousands of contracts. Relying on manual methods to manage these contracts is time consuming and unreliable. Poorly managed contracts also have a trickle-down effect—when contracts sit in limbo credentialing and enrollment processes are delayed which means providers can’t bill.

Automated contract life cycle management technology greatly speeds contract creation and approvals by aggregating everyone involved in the process of reviewing, signing, extending and renewing contacts into one workflow. Using a contract life cycle management tool, physician contracts are completed at an average of 31 days faster than using a manual process.

Considering the average daily billing total of $5,500 for a family practice physician, those 31 days add up to $170,000 of cash flow. Furthermore, contract life cycle management technology provides direct visibility into expired or expiring contracts as well as duplicate contracts. Setting alerts in advance of an expiring contract ensures nothing is overlooked or missed. It also affords staff time to identify opportunities to renegotiate better deals.

Re-evaluate credentialing and provider enrollment processes. Managing the credentialing life cycle can be a long and tedious process. When not done correctly, providers are unable to bill for services rendered, which negatively impacts an organization’s revenue.

The primary source verification (PSV) process can take months and requires diligent follow-up to ensure that all verifications are complete and accurate. Next, there is the initial provider enrollment process, which leverages essentially the same data gathered during the credentialing process, to secure a provider’s participation in health plans and achieve approval to bill the plan for services rendered.

Tracking deadlines and ensuring that a provider remains properly enrolled at all times is another time-consuming process that requires meticulous attention. Managing each provider through the process of primary source verification, privileging, and provider enrollment, as well as maintaining PAR status after the provider is enrolled, is laborious. Integrating credentialing and provider enrollment data into a single system that automates the workflow of the entire credentialing life cycle offers greatly simplifies these processes. Proactive reminders along the way and significantly streamlines and speeds up these processes.

Don’t underestimate the value of integrating contract and credentialing life cycle data. The ability to integrate contract life cycle management with a credentialing software offers huge benefits. Significant time is saved when duplicate data entry is avoided. Cross-team access to provider data allows everyone involved in getting a payer ready to bill to track where a contract is each step of the way. Setting automated alerts when contracts are complete means the credentialing team can immediately begin working on privileging and then enrollment. Integration greatly reduces the timeframe it takes for all of this to happen in comparison to each process being separate and disconnected.

Take a look at skilled resources. For large hospitals and health systems with hundreds, sometimes thousands, of providers, managing these processes in-house is often not possible. Organizations that lack the necessary staff and processes to manage contracts, credentialing and provider enrollment can expect a negative impact to their bottom line. If the volume is too high, consider an outsourced partner.

Look for a vendor with proven automated workflow technology that integrates the contract and credentialing life cycles. In addition to demonstrating proven best-practices procedures, the vendor should serve as a partner. This means working directly with key stakeholders to map out the most effective and efficient process to address both immediate and long-term project objectives.

Ensuring 100 percent participation status with every payer for each provider at every location they practice should be a standard goal for every hospital. An integrated approach for managing the physician contract and credentialing life cycle will play a key role in eliminating bottlenecks and oversights so physicians can get—and stay—billing.

Originally published: https://www.healthdatamanagement.com/opinion/physician-billing-holds-key-to-preventing-hospital-closures

How silos restrict key information sharing within hospitals

By Scott Friesen, CEO, Newport Credentialing Solutions

The healthcare industry is undergoing a massive change as it transitions toward a connected network of clinical and administrative services, with the goal of improving patient quality and clinical outcomes. However, as demonstrated through electronic health record systems utilization, an interconnected network can be a complex endeavor.

The rush to deploy EHR systems was driven largely by the Centers for Medicare and Medicaid’s Meaningful Use federal incentive program. Huge financial incentives helped speed the transition from paper to digital records. While great strides have been made in this transition, a new light has been cast on EHRs and the significant interoperability challenges that continue to exist.

Technology is rapidly advancing, and vendors have learned a lot from EHR deployments. Arguably, the biggest lesson is to address the continued need to easily share data between disparate systems. After all, no matter how much data is captured within a system, its value is greatly diminished when it can’t be shared with other systems, groups and organizations.

When left in their separate data silos, resources, outcomes, revenue and other areas are negatively impacted. As the industry looks for ways to enable true EHR interoperability, there are other areas of healthcare that can benefit from the lessons learned from EHRs’ shortcomings. One such area is provider data management.

Provider data management is a complex process involving many departments and individuals. The following is an example of how most hospitals manage their provider data today. The first provider data-rich department is the managed care department, the main task of which is to negotiate risk-based and fee-for-service contracts with payers. After contracts have been negotiated, the business development department hires providers or acquires them through mergers and acquisitions. After providers have been acquired, the human resources department manages any and all employment contracts for the newly hired or acquired providers.

Once hired, the medical staff services department, which is responsible for conducting all primary source verification services, conducts all vetting processes to prepare the providers for privileging. Once privileged, the provider enrollment department enrolls the providers with payers with which the managed care department contracted the provider or health system.

Ironically, after the provider enrollment application is received by the payers, those entities conduct primary source verification services similar to those conducted by the hospital to grant the provider access to their panels. Additionally, the purchasing department conducts all contract renewal processes related to the providers.

Despite significant overlap in data management, these departments historically never speak to each other, they typically use different systems, and none of the provider’s data is integrated into a single platform.

As evidenced by the fragmented health system example above, there is a significant need to tear down all provider data silos. However, this can only be accomplished by conducting a change in mindset. Namely, provider data management can no longer be viewed as series of individual departments, systems or tasks that do not speak to each other. Rather, it must be viewed as a lifecycle that can only be managed through a single, integrated, provider data management approach.

The importance of utilizing an integrated provider data management approach cannot be understated. Viewed as a lifecycle, an integrated digital backbone can help an organization by facilitating the collection, management and collaboration of provider data for every department that shares this data.

While each department may manage their respective tasks independently, utilizing an integrated digital backbone will allow each department to holistically view and manage where their provider is in the provider data management lifecycle.

The data within this hub can be easily accessible through advanced business intelligence by which any department can quickly and easily extract data for analysis. Analysis is essential to understanding where the provider is at any given point within the provider’s data lifecycle and can provide opportunities to improve both processes and revenue.

Hospitals and health systems have a unique opportunity to learn from EHR interoperability mistakes and get it right with provider data management. With the right mindset and integrated technology in place, data silos don’t have to exist.