Plan your business strategy down to a science. Then, implement those goals like the most significant game of chess you have ever played. You will have to see and understand each move, two, three, maybe even five steps ahead. Start with the credentialing process, one key, but exhaustingly tedious, move in jump-starting your revenue cycle. Now, how will you use your knowledge of the healthcare market to effectively employ your essential caretakers and revenue makers?
There is more to the story than just adding more manpower to your payroll. Consider your endgame: engaged employees, valuable healthcare, and positive operating margins, to list just a few. This is your objective and, you can achieve it by leveraging the credentialing process, including contracting, and enrollment, to empower, not just your healthcare professionals but your non-clinical workers too. Will you allow your office personnel to expend their skills on this front-end process or on other initiatives like patient retention and transparency, capturing small bills, and fixing claim issues among other concerns?
You only need one team of focused credentialing experts, ones that you don’t have to train in-house. Get a partner, an external stakeholder, because an outside task force could help to offset your costs of goods and labor, becoming the difference between your net gain or loss. They will set up your providers in the shortest amount of time within each payer’s timeframe, gathering data, negotiating rates, and completing electronic data interchange (EDI) enrollment agreements. There is no way around the long wait times, anywhere from 2 to 4 months, but the more efficient the process, the more likely you will avoid waiting to initiate revenue over an extended period of time.
Once you have onboarded your healthcare providers within your organization, your external administrators will make them more accessible to insurance payers. Each provider that is added to the CAQH (Coalition for Affordable Quality Healthcare) database is set up to contribute to your bottom line.
Payers, vendors, and other healthcare organizations can review documentation related to your providers’ education, reputation, and demographic information, including location, licenses, certificates, and so on. That background history includes the provider’s entity type 1 or 2, individual or organization, along with related NPI(s), Tax ID(s), and specialties/taxonomy codes. If your healthcare professional needs to obtain one or more of these IDs, then your external team can help them to acquire that information, like registering for an NPI on NPPES (National Provider Plan Enumeration System).
Moreover, your dedicated representatives will obtain all applications and signatures from the provider, track them in CAQH’s database, and keep you updated on the progress. Having all your providers’ identities in one location plays to the strengths of your business strategy. It allows your partner and stakeholder to assess your credentialing requirements, enabling them to determine what kind of relationship to build with each payer and how to negotiate the best reimbursement rates for you.
You have chosen a group of credentialing specialists and contracting strategists, they are aware of your organizational needs and the current state of the healthcare market. So, they can negotiate fair, reasonable, and relevant rates. According to CAQH, negotiations should center around long-term or short-term relationships, the payer’s reputation, and responsiveness, including their denial process, and their projected impact to your business. With this mindset, your team will get you in-network (or work on an out-of-network setup) for payers like Medicaid, Medicare, Tricare, Managed Care (MCOs), Commercial, and Multiplans across all 50 states. The objective is to make the most of the value-based pricing model to ensure better patient care, better medical costs, and ultimately, better pay.
At the final stage of initiating revenue, stands the EDI (Electronic Data Interchange) setup. Most if not all healthcare claim data is submitted electronically, which coincides with the electronic data housed within organizations like CAQH and NPPES. Thus, what’s on file in their systems should match what you submit on the claim forms electronically, including the provider’s name, NPI, tax ID, and other identification. Your credentialing account manager will make sure that your provider is approved to submit all the details of their medical services to the payer. Ideally, they will receive a reimbursement and move your organization one step closer to securing a profit.
If only you could recruit hard-working people with special skills and talents to “power up” your revenue cycle. They wouldn’t just initiate the payment cycle but light it up to run through faster and smoother than it ever has before. Each rotation, from credentialing to service to compensation, would easily skip forward due to their specialized knowledge and efforts. This means you will receive payments, reliably, within each payer’s schedule, and build innovation from steady streams of income. Is this your objective? If so, not only can you achieve it through your providers and non-clinical staff but also with outside reinforcements, like HealthRecon Connect, your healthcare support and a necessary part of your business strategy.
Deriise Dowell is an Atlanta based healthcare IT copywriter and advocate of efficient billing services, having served, empathetically, as an Enrollment Specialist and Technical Analyst for 11 years.
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