Payer Enrollment KPIs to Implement in Your Office Today

Payer enrollment or provider enrollment (PE) departments asked to report on key performance indicators (KPIs) for the first time often view it as a daunting task, and many aren't sure where to begin. The good news is, your CVO or PE office can start small yet make a big impact. The data your PE department or function collects in the form of practitioners’ personal and professional information is essential to the business side of medicine. 

“Provider data” encompasses information about individual providers, groups of providers, facilities, and organizations. While the term seems straightforward, it represents a complex array of information that healthcare organizations collect, standardize, analyze, and maintain in many different ways. 

Whether you’re starting from scratch on KPI development or seeking to gather more refined information for specific purposes, the answer is to start small and build from a few impactful data points central to your goals.

Why defined KPIs are essential in provider data management

KPIs are measures or metrics—in other words, specific data—intended to help your CVO or PE function track progress toward already agreed upon goals. Examples of those goals might be faster turnaround time, increased reimbursement, or a percentage increase of onboarded practitioners over a given time span. It’s likely that your office is already capturing some basic KPIs but perhaps is not yet reporting on them. 

There’s no dark corner of healthcare untouched by the need to collect large volumes of practitioner data to improve quality, safety, and reimbursement. The crucial data you gather and manage feeds into a vast network whereby:

  • Patients use it to select caregivers and employers use it to select a health network
  • States and other bodies use it for licensing decisions
  • Hospital and healthcare administrators parse it for patterns to make decisions about business processes and patient care
  • Regulators require it to ensure compliance on both the hospital and payer/health plan sides of healthcare

KPIs also matter closer to “home”

While your KPIs feed up into a healthcare system reliant on accurate provider data, there are other reasons for collecting and reporting on KPIs that hit much closer to home in terms of  professional growth and demonstrating how, and how well, your department functions. For the large number of medical staff offices newly taking on payer enrollment functions, sound data collection and reporting demonstrates how you (and your team) comprehend the changes coming and are onboard to help eliminate redundancies.

Responsibility for KPIs reflects an evolution of the CVO or PE function to a key role in the organization, and one that displays an understanding and willingness to be:

  • Transparent: As primary gatekeepers of all practitioner data, the buck stops with you. Patients, payers, administrators demand to see a complete picture of each practitioner —and data tells that story.​
  • Accountable: Every role in healthcare today is data driven, with success measured toward higher quality at lower cost. Practitioner data is at the center so the way it’s handled is critical.​
  • Recognized: It’s “what’s in it for you.” Leaders look to you to present data as a package that makes sense and helps in decision-making. Shine using your data—it’s the language of leadership.​
  • Ethical: Integrity speaks to trust as patients ask, “Where did the data come from and how can we know we’re safe?” Practitioners ask, “What are you doing with my data and how can I trust it will be used appropriately?” 

Starting point enrollment KPIs

Locating published lists of metrics that enrollment departments can track isn’t easy, and KPIs selected ultimately will depend on what’s important to your organization. However, billing companies, group practices, hospitals, ACOs—the full range of facility types that would enroll a provider to receive reimbursement—function in much the same way with regard to PE. As a result, there are obvious and common-theme benchmarks. In addition, there is a good deal of data sharing occurring in the profession.

In short, measuring KPIs and productivity entails looking at your process from start to finish, breaking it down into steps, and focusing on where backlogs may occur or where communication breaks down. 

Remember that KPIs are measures—not the actual goals or outcomes—and start here to construct or refine your data measurement system.

KPI #1: Turnaround time for application from provider

  • TIP: Check your instructions. Are they clear? Are applications paper or online? Do they delineate an explicit timeline? Can any items be completed by the department and not the provider?
  • TIP: Document each “touch” with every provider. Are they aware of the milestones they/you need to hit: application, onboarding, committee, start date?

KPI #2: Completion rate of application by the provider

  • TIP: Look for patterns in the data typically incomplete. What fields are mandatory versus optional? If not automated, can any portions go paperless? Is there data on the application that can be used again in credentialing, or HR, or billing?

KPI #3: Average time to submit completed applications to the payers

  • TIP: Determine whether becoming a delegated entity with a payer is possible. Are there payers with very similar requirements? Do some consistently take less time and therefore could be prioritized? Are steps documented to submit to the various federal, state, and commercial panels and are these clear to PE staff?

KPI #4: Turnaround time from payers

  • TIP: Track denials, rejections, data errors (typos), and procedural errors (missed deadlines). What’s the most frequent pain point causing lost time from each payer? Are there common denials due to incorrect or incomplete information submitted? Can you eliminate any multiple data-entry points?
  • TIP: Some payers notify a provider that an enrollment has been accepted, but not the healthcare organization. Are your providers instructed to check for this?
  • TIP: Check whether your state has enacted legislation mandating TAT from insurers.

KPI #5: Total days in enrollment 

  • TIP: Whether using software or a spreadsheet, track every touch point. The day the office is notified a provider will participate in plans is the first mark. Every email, call, or letter contact is a mark along the way until payer acceptance of a provider.
  • TIP: Check whether the payer itself offers a published average timeline and track to theirs. Or, use the general industry standard of about 90 days for comparison to your own DIE.

KPI #6: Participating percentage, or “par percentage”

  • TIP: Healthcare organizations that optimize reimbursement dollars do so using an industry standard calculation. While this encroaches the revenue cycle/billing arena, it pays for PE leaders to understand their part. The variables in the equation are your number of providers, number of service locations/addresses and number of payers. 100% participation would look like this:
              o   10 “participating” providers offering services at 10 locations fully enrolled in 10
                     payer plans = 1,000 opportunities for reimbursement

However, not all providers are enrolled in all plans, and/or do not provide services at all locations. Non-participating status may or may not mean the PE department is failing to capture potential opportunity for reimbursement. It also does not necessarily mean that claims are being denied. However, it is worth examining in cases where providers should be counted as “par” but are not.

Technology is the answer to creating efficiencies for KPI collection and reporting. Learn more today about symplr’s solutions for measuring multiple data points along the life cycle of enrollment and credentialing.

Learn how we can help you reach your KPIs

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