7 Urban Myths of Provider Credentialing & Enrollment

In every profession, myths and fallacies based on misinformation persist year after year, until they become urban legend. Perhaps there was a kernel of truth in there somewhere, at the start. But like in the kids’ game telephone, distortion takes over, the source long blurred and unknown, and the fiction lives on.

Let’s take a moment to identify and debunk some urban myths of credentialing and provider enrollment.

  1. If a payer declines to add your provider to a panel, there’s nothing you can do.

Actually, there are numerous ways to try getting past a payer’s denial when you’re trying to enroll a provider into an insurance plan. You can appeal, and second-level appeal. You can offer the payer additional (appropriate) key information that makes your provider essential to that payer's panel needs. You can negotiate terms, offer an initial trial, or try other creative paths. It may not happen overnight, but persistence often pays. Learn more here.

  1. Credentialing/medical staff services is not a part of the revenue cycle.

Times they are a-changin’. The healthcare revenue cycle historically referred to claims processing and payment collection. Now the term captures a fuller picture including providers’ and the medical staff/payer enrollment administration’s contributions to revenue. Both the Healthcare Financial Management Association and the Healthcare Information and Management Systems Society define revenue cycle as administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue. That includes primary source verification, credentialing/privileging, and enrollment, which all start the path leading to profit.

  1. Group practices can’t survive unless they enroll providers with government or commercial payers.

In more ways, patients are becoming payers because they now have many platforms to choose from (urgent care, telemedicine, drugstore clinics, etc.), don’t care to have a PCP, or opt to cut out the "middle man" (in this case the insurance company) to receive care. Concierge care through an agreement directly with a physician group and many forms of direct to consumer care are thriving. A growing movement of pediatricians, family-medicine physicians, and internists are opting for a model where the doctor’s office charges a monthly fee and doesn’t take insurance. High-deductible plans/high out-of-pocket costs through traditional health insurance companies are driving new formats for care delivery and payment.

  1. The most efficient order is: hire provider/set start date, credential/privilege them, enroll with payers.

Actually, if this is the order your healthcare organization follows, you might be:

  • Leaving reimbursement money on the table
  • Inconveniencing the provider or patients
  • Putting the control in the payer’s hands
  • Doing double time on some cred/PSV steps

Check out #2 in this article.

  1. CVOs are for primary source verification, and their use makes you more likely to be scrutinized by accreditors.

That's a "no," on both accounts. If you use a credentialing verification organization (CVO), you won’t be painting a target on your back for accreditors. And you’re in great company. CVOs have reached near saturation, meaning most health systems have an internal one or use an external/commercial CVO. NCQA certifies about 200 of them, and URAC certifies an undisclosed number. And CVOs offer both hospital and managed care CVO credentialing, are typically paperless or close to it, and may do everything from application management, verification, and expirables management to recruiting, enrollment, privileging, and FPPE/OPPE. 

  1. You must turn over your policies and procedures to your Joint Commission, DNV, CMS, or other surveyor when they ask.

Negative. There is no requirement that you give surveyors copies of your policies and procedures to take away, either electronically or hard copy. They may ask, and often do so, when they find policies or other material they especially like. However, it’s your call about giving anything away. There is no advantage for you to let them take it. Need help with best practices and preparing for a survey? symplr can help.

  1. If a surveyor cites you on something, you can’t do anything about it until you receive the results post-survey, then appeal.

Wait a second.... I’m mean, don’t wait! Your surveyor may not share this tidbit, but while they’re still onsite and there’s been an area of potential non-compliance identified, you can try to nip in the bud. If you believe they’re making a mistake, ask for a call with the surveyor and their “mother ship” asap. Have the regulatory or accreditation language in question out and ready, have your policies and procedures/bylaws language ready, and invite along any big players needed on your side (e.g., a physician leader, CMO/VPMA, Quality VP, etc.) to help you state your case.

There you have it. Now you can help your fellow provider data management professionals avoid the pitfalls associated with these urban legends.

Need to elevate your provider data management game? Ask symplr. 

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