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Introduction to Payor Enrollment January 14, 2015 Donna Goestenkors, CPMSM and Dina Solis
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Introduction to Payor EnrollmentJ a n u a r y 1 4 , 2 0 1 5
D o n n a G o e s t e n k o r s , C P M S Ma n d
D i n a S o l i s
Donna Goestenkors, CPMSM+ Team Med Global Consulting,
LLC
Dina Solis, Owner+ Sonoma Credentialing Services
Leadership, Exploration, & Development
Objectives
+Understand the basic principles & resources of Provider Enrollment.
+Answer your questions about Provider Enrollment.
Prepare Yourself
“You have powers you never dreamed of. You can do things you never thought you could do. There are no limitations in what you can do except the limitations of your own mind.”
--Darwin P. Kingsley, Business Leader
Answersto your
Enrollment Questions
Questions From The Field
+“Is this my future?”
+“What if I’m unhappy in my job?”
+“What should I do if I’m seeking a new challenge?”
+“What’s involved?”
+“Do I have the skills?”
How To Get Started
+Enrollment is a part of the Medical Staff Services Industry.
+Embrace the change!
+Reach out to a mentor.
+Have a career plan!!
What Is It Called?
+Payor
+Provider
+Enrollment
+Contracting
+Credentialing
What is Enrollment?
Enrollment is the process of applying to health insurance plans/networks for inclusion into provider panels.
Allows the provider or group/organization to bill the insurance health plan for services rendered to the plan and for health plan members.
Types of Enrollment
+Federal & State
• Medicare/Medicaid
• Tricare
+Private/Commercial
• Blue Cross/Blue Shield, Aetna, United Healthcare, etc.
+Workers’ Compensation
• US and State Departments of Labor
• Various Workers’ Comp MPNs, Plans and PPO Networks
Who To Enroll
Individual Provider vs. Group Provider Enrollment+Depends on who the billing will go through
(Individual NPI or Group/Org Tax ID).
+If enrolling Group, individual needs to also be enrolled and benefits are normally assigned to the Group.
+Identify your organization’s internal enrollment processes (if any!) before starting.
+Identify desired health plans to enroll in.
Time Frame To Enroll
How long does the Provider Enrollment Process take?+Processing times vary by payor – contact the plan
and ask!
Enrollment Process
+Contact Provider Enrollment or Provider Relations
+Refer to each payor’s website for guidance
+ Process Overview
+ Forms
+ Requirements
+ Processing Timeframe
+ Submission Method
+ Key Contacts
Utilize Your Resources
Applications, applications and more applications!Credentialing software can help automate the application process by auto-populating, tracking, and even submitting applications
+ Medkinetics (now symplr), IntelliSoft, Sy. Med, Morrissey, Cactus, etc. =
Auto-fillable applications
+ Some plans have auto-fillable forms you can download from their website
+ Credentialing software can help automate the application process by auto-populating, tracking, and even submitting applications
+ For paper applications, urge your organization to obtain the full version Adobe Acrobat Pro. No handwriting!
More Resources ~ CAQH
Pros
+ Online
+ Some Health Plans able to download without paper shuffling delays
+ Quicker, as long as information is current
Cons
+ Initial administrative paperwork
+ Provider’s information needs re-attested every 120 days
+ Upload Separately (time consuming)
+ Current documents
+ DEA
+ Malpractice cert, license, etc.
Even More Resources & Tips!
+ AIS (Atlantic Information Services) Directory of Health Plans 2015:
+ Comprehensive directory of all US health plans with member enrollment, plan type, demograhic and contact information.
+ Print, CD, and USB Flash Drive database formats.
+ Website: www.aishealth.com for purchase information.
+ Take the time to accurately enter provider data on applications and in CAQH and software.
+ Electronically Save, Re-Name, and Upload provider’s credentialing documents separately ahead of time. No bundled docs!
+ Audit your work. Twice!
Provider Relations
Key Success Tips+ Get to know your provider representative by
name.
+ Use your skills as a Leader to impact the process.
+ Stay actively connected to maintain relationships, facilitate information flow and trouble-shoot.
+ THANK them, frequently.
+ Connect with them on LinkedIn.
Enrollment Challenges
+ Credentialing applications can be lengthy.
+ Credentialing processes & times vary greatly by payor.
+ Attestations are frequent/quarterly and require tracking.
+ Payor databases not updated reflect provider.
• Payor contracting dept. and network development communication delays.
+ Paper applications can require original signatures.
+ Failed online log in attempts can lock out the user.
+ Communication restraints with providers.
More Challenges!
+ If information is missing or if documents are outdated, the insurance plan will contact provider.
+ To avoid delay, it is essential to have all the information current, and use only the current versions of any applicable forms or applications.
+ Application errors or omission can delay health plan members accessing services from the provider.
+ Enrollment delays, errors and omissions cause payment delays and issues for the provider/organization!
Roadblocks
Things That Delay Payor Enrollment
+Incomplete training dates
+Inactive State license
+Inactive DEA
+Inactive malpractice insurance
+Inactive hospital membership/privileges
+Errors and/or omissions of application information
+Missing supporting documentation
+Lack of response to payor requests for additional info
Success Points
+Begin the enrollment process immediately upon colleting information.
+Automate the enrollment process to the greatest extent possible: Medkinetics (now symplr™) CAQH, database software, Morrisey, IntelliCred, HealthLine Systems, Cactus, etc.
+Minimize the use of paper forms whenever possible.
+Respond to payor requests as soon as possible!
+Communicate proactively with providers!
Final Steps
+If Enrollment is Approved
• Insurance plan contacts provider (letter)
• Provider is linked to the group
• Provider is activated with effective date
+If Enrollment is Denied
• Insurance plan notifies provider
• Plan asks provider to reapply in “x” months
MSP Value
+Enrollment Management
• Federal requirements
• Health plan requirements
• Resources
• Technology
• Stakeholder satisfaction
Reality
Power Thought
“Your resources are always far greater than you imagine them to be. Never ask, ‘Can I do this?’ Ask instead, ‘How can I do this?”
--Dan Zadra - Author
Save the Date: Enrollment Series
Session 2: “Enrollment 101”
Wednesday, February 11, 2015
Noon – 1:00 p.m. CST
Session 3: “Enrollment 201”
Wednesday, March 11, 2015
Noon – 1:00 p.m. CST
Speaker Contact Information
Donna Goestenkors, CPMSM
+ Team Med Global Consulting, LLC
+ Telephone: (618) 830-0057
+ Website: www.teammedglobal.com
+ Like Me: www.facebook.com/teammedglobal
+ Connect with Me: www.linkedin.com/donnagoestenkors
+ Follow Me: www.twitter.com/teammedglobal
Speaker Contact Information
Dina Solis, Owner
+ Sonoma Credentialing Services
+ P.O. Box 4661
+ Petaluma, CA 94955-4661
+ Telephone: (855) 707-9995
+ Website: www.sonomacredentialingservices.com
+ Like Me: www.facebook.com/SonomaCredentialingServices
+ Connect with Me: www.linkedin.com/in/dinasolis
Credentialing Tool
The Medical Services Professional Career Guidebook
Features include:
+ Frequently asked career questions by MSPs
+ Sample job descriptions, career assessment tools, competency development plans and more
+ Real-life stories to illustrate career decisions
+ Purchase today or order your copy:
• www.teammedglobal.com
Team Med Global Newsletters & Blogs
Thank You!
