While the biggest changes transforming hospital care are apparent— payment systems are rewarding value over volume and technologies like telehealth and minimally invasive procedures are remapping where and how patients receive healthcare—a quieter development is occurring in the medical staff services offices of hospitals.
Many health systems are seeing a precedent to use the medical staff office as a catch-all. Unfortunately, it may be taking on many consequential tasks related to a health system’s business and quality functions, but without the benefit of its staff receiving sufficient support. Medical credentialing and clinical privileging have always been the bread and butter of the medical staff office. Now, new responsibilities in payer enrollment and provider performance monitoring have shifted to the office. A recent survey by symplr of 118 medical staff professionals (MSPs) found that many medical staff office personnel feel unprepared to handle the changes underway. The most commonly lacking resources cited in the survey responses are related to:
- Planning and oversight of new functions
- Education and training for changing job skills
- Software and technology needed to keep pace with change
This eBook looks into the evolving medical staff office—a hive of activity for the intersection of clinical and administrative functions in hospitals.
The medical staff office is essential
The MSPs who run the medical staff office collect and manage provider data, which facilitates the delivery of safe patient care and contributes to overall hospital and provider success. The administrative work behind making providers available for every patient must be seamless to the patient and the provider. This is where the medical staff office comes in, helping the organization ensure that clinicians with the right credentials are vetted, available to care for patients, and participating in health plans.
Of the various logistical and operational responsibilities that the medical staff office handles daily, provider data management is perhaps the most important. It entails gathering, analyzing, and maintaining providers’ lifecycle data. But in most health systems, provider data management has grown to encompass more than just data processing.
The typical medical staff office is responsible for the following activities:
- Onboarding: This step often includes contracting, which may include compensation, bonuses, relocation assistance, tuition reimbursement, and more.
- Primary source verification/credentialing: A provider’s credentials include their education, training, licensure, board certification, references, insurance, and more. This step requires tracking down and often communicating directly with a representative of the “primary” source, or issuer of the data or document, to verify its authenticity. Technology now automates some verifications.
- Privileging: After the medical staff office verifies a provider’s credentials, clinical leaders use the data to determine the privileges—the specific procedures and services—it will delineate to the provider in a given facility or network site. MSPs conduct clinical research and keep privilege delineation forms up to date. Privileges may differ between sites, even in the same healthcare system.
- Provider enrollment: Enrollment of providers into government (e.g., Medicare and Medicaid) and/or commercial (e.g., Cigna, UnitedHealthcare) health plans is required before the hospital can bill for services.
- Provider performance monitoring: Often, the medical staff office works in conjunction with the quality department to gather and report on providers’ performance data at regular intervals for the purposes of accreditation, reimbursement, and providers’ personal/professional improvement. Performance increasingly affects reimbursement under value-based care.
- Provider relations: The medical staff office performs a litany of other provider-related duties, including:
- Committee preparation and management
- Coordination and/or tracking of providers’ continuing medical education activity for maintenance of board certification
- Accreditation and regulatory compliance activities related to the medical staff
- The development and/or maintenance of medical staff governance documents (e.g., bylaws, policies, and procedures)
In fulfilling all of these obligations, especially enrollment and performance monitoring, the medical staff office’s work has a tangible impact on billing and the revenue cycle and the business of healthcare.
In addition, MSPs’ role in helping physicians acclimate to the non-clinical aspects of their jobs is
an important and growing one, according to the symplr survey. Ninety-one percent (91 of 100) of MSPs responded that medical staff leaders rely on them more or just as much as they did in the past for support and education.
It’s likely that the C-Suite will increasingly rely on the organized medical staff’s input amid healthcare consumerization and other changes that value providers’ front-line clinical experience. Clinicians contribute to overall healthcare governance mainly through departmental leadership positions and on committees, which the medical staff office helps them prepare for. symplr survey respondents reported on the areas where they support the medical staff the most.
Medical staff offices and resource management
Signs show that hospitals’ reliance on the medical staff office will only grow in the coming years as the following trends persist or take shape:
- More providers opt for hospital employment over affiliation, meaning there are more of them to onboard, credential, enroll, privilege, and monitor for competency
- More nonphysician providers’ scopes of practice are expanding at the state level, requiring them to be privileged through the medical staff office, many for the first time
- Mergers, acquisitions, and medical group consolidations keep rising, causing spikes in credentialing and enrollment volume for the medical staff office
- Payer enrollment responsibilities emphasize the medical staff office’s accountability for speed and data integrity like never before
Unfortunately, there is no standard or recommended ratio of MSP-to-provider. Many of the medical staff office personnel in symplr’s survey report being a “team of one,” a “skeleton crew,” or state that they must rely on part-time or non-salaried help, even as their workload grows.
Asked to identify their biggest challenge, 36% of MSPs surveyed (34 of 93) said that despite the growing volume of work, staff resources are insufficient.
According to one respondent, “A great deal of responsibility from all areas and departments have been added to our shoulders with no possibilities of additional help, or splitting out of specialties within the MSO office…”
In addition, nearly a third of MSPs surveyed by symplr said their organization does not have documented best practices for managing provider data, presumably leaving them to create workflows and processes while handling a growing volume of work.
Having documented policies and procedures is especially important as healthcare M&A activity continues, to avoid the possibility of conflicting policies across systems. Such discrepancies can render health systems noncompliant with accreditors and bring fines from regulators. In addition to having written workflow protocols, keeping formal job descriptions up to date helps to avoid situations where self-taught personnel lack training or skills that reduce their effectiveness.
Education and training for the future medical staff office
Numerous factors related to provider data management are changing the medical staff services profession. It will be challenging for any medical staff office to handle the conversion. Success will depend on educating and training MSPs to learn new parts of their healthcare business. In addition, they will
need to restructure their workflows and priorities to match the expectations of hospital and health system administration and the organized medical staff.
Unfortunately, education and training may be lagging, as indicated in many of the survey responses. Nearly 40% of MSPs (46 of 118 respondents) recognize that they will need additional knowledge or skills to conduct their jobs.
When asked about the biggest challenge with regard to provider data management, the responses ranged widely. Common themes were role expansion to new areas that will require training, the need for additional workforce resources, or technological deficiencies.
The MSP’s biggest challenges:
- “We are now data analysts and professionals in data integrity. From the inception of OPPE/FPPE data collections, management, and housing, to managing and maintaining privileges and needing to know the newest requirements for privileges (even though we are not clinicians).”
- “All of these responsibilities have been added to our shoulders over the past 10-15 years and [billing and provider enrollment] within the past 3-5 years… All [have occurred] without expanding our office personnel numbers.”
- “[The lack of] the company’s investment in technology/ software to perform the required responsibilities in an efficient manner.”
- “Doing the job using old methods and technology.”
- “Having the best up to date software in order to do our jobs to the best of our ability.”
Lack of recognition and/or cooperation was also a prevalent theme. The following were additional responses to the question, “Identify your biggest challenge:”
- “Getting leadership to see the value in the Medical Staff Office all the time and not just at the time of survey.”
- “Provider participation! It can be impossible to get providers to respond, therefore making it difficult for the MSP to do their job!”
- “Needing respect/support from administration.”
One survey respondent suggested the need for clinical specialty training among MSPs to handle the role’s increasing influence in maintaining clinical privilege forms and performance monitoring: “We are expected to be the expert in all aspects [of provider data management], which leads to errors. How about teaching hospital MSPs and more importantly, MSO managers, on how to branch out into ‘specialty’ areas…?”
Another survey respondent pointed out that even when some tasks, like billing and payer enrollment, are outsourced to a third party, the medical staff office still must manage the relationship, and that drains resources: “Dealing with Billing Agencies on how to bill a facility setup with various payors [is a challenge]. They always look to the credentialing staff for advice.”
Payer enrollment, reimbursement take center stage
It’s essential for hospitals to recover all possible reimbursement to fund all kinds of initiatives for growth amid competition. Patient care and subsequent billing for services would not occur without successful provider enrollment into Medicare and Medicaid and commercial health plans.
At the same time, health systems seek to eliminate redundancy in administrative tasks. As a result, many organizations have merged credentialing and payer enrollment (also called provider enrollment). Enrollment is time consuming, considering that the average practitioner may enroll into 6-10 different plans, all with varying data requirements and rules.
But for many medical staff offices, the exposure to managing payer relationships is new, the associated steps are self-taught, and the office relies on its existing credentialing/privileging software to accomplish the task. If MSPs in the medical staff office are insufficiently supported in their roles in payer enrollment, there may be detrimental effects on the revenue cycle.
Despite this, symplr’s survey found that technology for the specific tasks within enrollment may be lacking:
In addition, the survey respondents indicated that the negative effects of lacking resources may go beyond reimbursement, to affect customer service issues:
It’s not just about the bottom line. In markets where competition for providers is fierce, customer service and ease of use for practitioners matters. File backlogs, separate credentialing and enrollment forms that request duplicate data, and unfilled provider positions over time are symptoms of an organization’s technological inefficiencies.
Despite the high costs of credentialing and reimbursement delays, 43% (41 of 96) of MSPs in symplr’s survey do not have real-time access to all of the data they need.
Regarding enrollment status, 68% of MSPs (54 of 80) responding to symplr’s survey reported an inability to see the real-time status of their providers’ progress for enrollment into insurance plans.
Tools for medical staff office success
Healthcare organizations invest in various enterprise-wide and department-specific software applications—from electronic health records (EHR), to platforms for billing, credentialing/privileging, enrollment, and human resources. The challenge: These and the many other disparate hospital and physician practice software platforms often don’t share information.
Accomplishing new tasks by using old technology is a hurdle for the medical staff office, according to symplr’s survey. Some 32% (30 of 93) of MSPs reported that their software, technology, or technological expertise is lacking.
Roughly 71% of MSPs in the symplr survey (55 of 77 responding) reported using 2-5 solutions for their job, although technology that integrates all information data for complete provider data management is available.
These data silos between systems acutely affect the medical staff office because MSPs must reenter information found in the human resources, EHR, quality, or other systems into the credentialing software. It’s often performed manually using spreadsheets as the go-between for multiple systems, slowing the onboarding of new clinicians and making it challenging to maintain accurate information for those already practicing at the organization. It also leaves the provider organization at risk of noncompliance or patient harm due to human error, and exposes providers’ personal data more times than is necessary.
Only about half of MSPs in the symplr survey (51 of 94) said their credentialing and enrollment data is stored in one solution or place.
Having numerous employees hospital-wide generate and maintain the same data in various platforms, across the enterprise, creates waste and makes the status quo a costly proposition.
In the symplr survey, the majority of MSPs—49% or 38 of 77 respondents—enter identical data into two or three software systems. An astounding 16% (12 of 77
respondents) said they must enter their provider data into 4-6 different systems.
A digital, future-ready medical staff office
Patient care and subsequent billing for services would not occur without the successful management of provider data performed in the medical staff office. And there’s no dark corner of healthcare untouched by the need to collect and manage ever-growing volumes of accurate provider data to improve quality and safety.
In fact, provider and health plan data feeds an increasing number of internal and external uses for the business of medicine, including the following:
- 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
It benefits hospitals in countless ways to support the planning, training, and technology needs of the medical staff office. Investing in the medical staff office is the only way forward for hospital success.
Contact symplr to learn more about the growing importance of the medical staff office and explore our solutions to maximize its impact on safety and financial incomes.
