Enrollment vs. Credentialing vs. Facility Privileges

Categories: Billing, CHC, PMG Insights Blog

April 17, 2017

Stressed CEO versus Happy CEOTo many in CHC leadership, these three topics can be confusing. To maximize reimbursement, while staying compliant with governmental regulations and payer contractual language, it behooves CHC fiscal and RCM (revenue cycle management, a.k.a., billing) team leaders to peruse this article for a brief overview.

NPI Overview

Before we even begin to delineate definitions of terms here is a quick review of NPI obtainment and why it happens. The National Plan & Provider Enrollment System (NPPES), is the entity responsible for the assignment of a unique “national provider identifier” or NPI. Remember that the1996 Health Insurance Portability and Accountability Act (HIPAA) mandated there be a single provider identifier to be used by all payers. Prior to HIPAA each payer had their own unique provider identifiers. In other words, if a doctor was a participating/credentialed provider with 10 health plans or payers, s/he would have 10 unique provider identifiers. Have just ten doctors in a practice, participating in the same or often different payers, and you have more than a hundred provider identifiers to track/manage. Just keeping track of all the numbers was maddening, never mind for each payer understanding or maintaining active status.

So, with HIPAA and via NPPES, each provider (and for CHCs typically each facility) must obtain a unique NPI. This NPI will follow individual providers (i.e., docs, NPs, PAs, CNMs, etc.) for the entirety of their career. Certainly, this was done to mitigate fraud by limiting the number of active provider numbers in the marketplace but also to allow payers as well as state and federal government to track providers, especially problem providers.

Enrollment

Simply stated, this is the process of getting a facility or individual provider NPI to be “active” or “participating” with a third party payer. Each payer is unique and while some (often many) use the same or similar application and/or process, each requires an NPI be uniquely “enrolled” to obtain “par” (short for participating) status. Most times when a CHC or a company says they do “credentialing” they really are moving through the enrollment or payer application process. Making payer application is entirely different from the vetting and approval process that really is credentialing.

Credentialing

As stated, enrollment is the making of an application while credentialing is the actual vetting process to determine whether a provider is worthy of “participation” or “par” status. Initially, the most basic demonstration of qualifications is necessary. These include but are not limited to:

  • Necessary credentials/degree (e.g., MD, DO, PA, NP)
  • Residency or training
  • Board certification or advance training
  • Drug Enforcement Agency (DEA) number
  • State/federal licensure

Some payers want these data conveyed electronically while many still require a paper process. Regardless, providers or their authorized representatives must make attestation regarding any malpractice and/or other incidents related to professional service and answer a myriad of probing questions. After all these data are gathered, the payer/plan credentialing team perform “primary source verification” which means they verify submitted info by contacting medical/graduate schools and residency/training programs to confirm dates and degree status, they research DEA or state license status and any accusations or instances of malpractice, and generally make certain the data submitted is in fact an accurate and complete picture of the applicant’s educational and professional history.

For Medicare and Medicaid, these payers also make certain the applicant is not in default status on student loans… a violation which will disallow their “par” status with any governmental payer and make it illegal for CHCs to obtain Medicare/Medicaid payment for work performed by these fiscally delinquent providers. Remember this includes Medicare Advantage and any managed Medicaid programs as well since these are funded by governmental dollars.

Once the application is deemed “complete” the provider/facility is presented to the payers’/plans’ Credentialing Committee at which “par” status is granted or withheld. These committees often meet only monthly so missing information or delayed response to payer inquiry can push credentialing decisions back often at least a month… another month of that provider seeing patients for free.

These costly delays are all too common unless a CHC enrollment team is truly on the ball and understands exactly what is needed for each payer and by what deadline. This is not easy stuff nor is expeditious credentialing commonplace. Delays occur largely because this enrollment and credentialing oversight is typically “part-time” work for a CHC employee with other primary work responsibilities.

Facility (e.g., Hospital) Privileges

Like payer/plan credentialing, facilities (e.g., nursing homes or hospitals) require a vetting before allowing providers to see or treat patients at their facilities. They require basic applications with the requisite data already mentioned above in the credentialing overview. Like payers, they have a regular (often monthly) leadership meetings (sometimes multiple) during which applications are approved or denied. They also will determine what procedures/diagnostics the requested privileges will allow as well access to which departments/floors/services the provider will have. This is usually based on state scope of practice and unique training/certification held by the applicant.

For many CHCs, facility privileging can be a bit foreign if only because hospitalists are the norm. For those not familiar, hospitalists are groups of providers whose only function is to manage patients in a facility setting. Most often hospitalists have no private practice (are not CHC employees) and only see patients of other private providers when those patients are admitted to a facility. If your CHC covers a rural marketplace or struggles to engage a group of hospitalists to manage your CHC patients when they need to be admitted to a hospital, nursing home rehab center, etc., your CHC must understand the process and minimum requirements to obtain and maintain active facility privilege status.

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Summary

While it is not hard to understand these three distinct terms and how they relate to your CHC, maximizing the process and fiscal opportunity is. Too many CHCs see significant denials or delayed payments because:

  • CHC employed providers or facilities are not adequately credentialed
  • CHC providers can’t or won’t be credentialed due to work, licensure, or malpractice anomalies
  • CHCs struggle to manage internal resources/information to maintain active “par” status through re-enrollment

CHC mastery of credentialing/enrollment is quite difficult not because it cannot be learned but because it is so episodic. It is difficult to maintain skills when they are used so intermittently. So, two choices exist, allocate money and resources to maintain a true in-house expert or hire outside help from a firm who does enrollment/credentialing all the time. The latter is often incredibly cost effective and allows your CHC to focus on what it does best… bringing down barriers to care for those community members (i.e., patients) who need your CHC services.