The ability to reach your organization’s overall revenue goals is a balancing act in today’s competitive business environment. As a result, achieving maximum reimbursement when enrolling practitioners into payers contributes to financial stability and success. Costly and time consuming errors and roadblocks can cause denials or delays, eating into reimbursement. But often, these errors are easily corrected.To stem the most costly payer enrollment errors, examine a few key areas of your organization’s interface with payers to identify where leakage might be occurring, know the market and understand your contracts, and keep the lines of communication with payers open and ongoing.
Error #1: Failing to conduct a market analysis of payers
CMS projects the number of Medicare beneficiaries to grow to 80 million by 2030 from 50 million today. A forecast that strong means government and state payers are a must-have for most group practices. It’s true that some practices don’t take private insurance (i.e., fee for service/cash only)—for example if they’re seeking to create an upscale, cosmetic-type practice. But if you’re reading this article you’re a key link in your organization’s financial success, which likely is dominated by both government payers and commercial or private insurance companies, HMOs, and PPOs.
It’s among private commercial payers either national or local/regional where choice and control come into play. The American Dental Association (ADA) calls the decision of whether to contract with any third-party, non-governmental payer “by far the most important decision for your practice.”
Practices with business savvy know their target market today and whether it’s likely to change. They’ve researched the business landscape to identify the largest employers in their community and the plans they offer to employees. They’ve determined what insurers will give them the most bang for the buck based on the time and effort enrollment and re-enrollment require.
A market analysis entails asking questions such as:
- What insurers represent the major employers in your area?
- What insurance types do your referral sources and local hospitals accept?
- What is the competitive business and socio-economic landscape of your practice’s or network’s location(s)?
- What’s your target market(s) and what are their needs today and in the future?
- Are patients in your target market willing to pay out of pocket for any items and services provided, beyond what’s covered by an insurance plan?
- Which insurers offer lucrative benefits that correlate to the service aims of your practice today and in the future?
Enrollment and credentialing rules and requirements differ from state to state and from plan to plan, so for practices, commercial contracts are not “one size fits all.” The largest national or regional commercial insurance companies (e.g., UnitedHealth, Anthem, Aetna, Cigna, Humana) typically offer better-paying panels, but are private and as such don’t have to accept all practitioners into their panels. Take the time to review your options payer by payer to understand which best fit your current patient population and future practice plans.
Error #2: Not using technology to expedite provider enrollment and automate applications
Enrolling and managing payer contracts and provider applications is time-consuming. It also takes fortitude to “stay on the ball” until all providers are considered participating (or par) with all requested payers.
There’s an opportunity to use one technology for the entire life cycle of a practitioner or payer contract, fostering the ability to more effectively share data, ensure data integrity and transparency, demonstrate accountability for large volumes of traceable data, and handle rapid growth in provider numbers. Batch processing and form-automation technology in payer enrollment software answer the need to create efficiencies.
The time-consuming workflows that go hand-in-hand with payer enrollment include:
- Primary source verification
- Contracts management
- Internal/external communication of application or enrollment status
Contract template and letter creation functionality, e-signature, and web views are examples of functionality that allow single- or multi-entity healthcare organizations expedite and manage the contracts process.
Error #3: Failing to maintain provider data and contracts for enrollment, re-enrollment, and unenrollment
Practitioners change locations, group affiliations change, and licenses expire. Theseare examples of activities that represent challenges to maintaining a steady flow of payer reimbursement for healthcare provider organizations. As a result, it’s essential to maintain up-to-date information to stem any negative impact on claims and to avoid costly errors.
Outdated or false information in provider and group practice directories leads to claims that are denied or falsely paid, inviting fraud and abuse investigations or fines. But auditing to manage claims data at the group practice level is simplified when all of the information regarding the individuals and entities being audited exists in one database with notification, letter-writing, and reporting capability.
In addition, financial risks lurk in a system where contracts management is disorganized and not synced to individual practitioner enrollment and re-enrollment. Exercising control through rigorous upkeep of data helps healthcare organizations take charge of their growing number of payer contracts—from negotiation through renewal—with health plans.
Error #4: Not delegating the enrollment function when it makes financial sense to do so
Delegation is an optional, formal process whereby a healthcare organization’s or health plan’s department responsible for credentialing and/or enrollment agrees to turn over some function(s) to a qualified organization. Done well, delegation can save time and money by freeing staff to focus on competing priorities.
Most delegated relationships are for NCQA-certified organizations enrolling +150 providers, but every payer/health plan sets its own standards for what’s acceptable. A threshold number exists because efficiency is delivered only once a certain volume is reached.
Tips for a successful delegated relationship:
- Know your contractual responsibilities as they differ by payer
- ID whether delegation carries obligations to participate with certain products or services offered by the payer
- Investigate whether upgrades for patient products or services are allowed, and under what circumstances and by what method of request to the payer
- Ask whether the payer will provide an advanced copy or a sample explanation of benefits form that patients of your practice or organization will see
- Related to turnaround time: Ask what the process is for claims submission and denials
- Learn about whether the payer notifies the provider and the practice when par is achieved. (Some payers notify only the provider, leaving the practice out of the loop)
- Expect an audit to performed at least annually (either side—healthcare org/health plan or payer)
- Ask whether an agreed-upon processing timeline can be established, and discuss expectations for renegotiation if needed
- Gain mutual understanding of the unenrollment process steps and notification timeline
Error #5: Failing to ask the right questions when a provider is denied enrollment
Because all subsequent payments flow from enrollment into one or more payers, hearing “no” from any payer is seen at the organizational level as a loss of potential revenue. Denials can happen: Payers have the ability to set and adjust the number of providers allowed into their networks and to determine their qualifications. They institute limits while walking a fine line to save costs yet ensure their ability to deliver healthcare benefits promised to enrollees. Thus, a provider’s application to an insurance panel can be denied for various reasons, application-error related or otherwise.
Medicare may mark certain geographic areas subject to competitive bidding limitations on reimbursement of certain services or products—or there may be a moratorium on a certain provider type, or in a specific geographic region.
Other common reasons for denials include:
- Failure to meet certain criteria or provider standards set by the payer
- Being out of compliance with requirements of a payer’s Conditions of Participation
- Over-saturation of a provider type in a community or service area
- Restrictions on or failure to meet additional requirements for out-of-state enrollments
Request to submit additional information to get past the payer’s denial with an appeal, to clarify what unique or special patient community your provider services, and to request a conference call or face-to-face meeting with a decisionmaker so you can verbally and effectively convey your message. Persistence often works.
In addition, if your provider serves any of the following populations, be sure to communicate that fact:
- Indian Health Services
- Chronic condition
- Any non-English-speaking population