Provider Enrollment & Credentialing: Solving Enrollment Issues

Categories: Billing, CHC, FQHC, PMG Insights Blog

January 5, 2018

Doctor saving you money

We at PMG have never seen an FQHC that is not working tirelessly to obtain maximum reimbursement. You found the right staff, you finally have claims going out the door in a timely manner, and yet you can’t seem to pinpoint why your revenue cycle is not optimal. In today’s post, we encourage you to look beyond the billing department to examine how provider credentialing issues can bring down your bottom line. Statistics indicate that 1 out of every 3 billing denial stems from credentialing. So what are some ways you can get ahead of the curve and climb that ladder to fully optimized revenue?

FQHCs search high and low for the best billing staff to ensure their revenue cycle is up to par. Provider Enrollment, however, is often woefully neglected. Far too often we see CHCs place the burden of payer credentialing on their billing or HR departments. Navigating the insurance enrollment process is a daunting task and requires highly specialized individuals that have a good handle on all the ‘in’s and out’s.’ Ensure that you have the internal resources dedicated to provider enrollment. Spend time in hiring a qualified person to handle this at your CHC or provide training for existing staff; in the case that you just cannot find the right person outsourcing is another valuable option. Full disclosure, PMG offers this service, but that has allowed us to see first hand how having experienced staff can make all the difference. Knowledgeable staff or outsourcing to experts can ensure that the process is handled correctly the first time around. This is the first step in reducing your pesky ‘provider non-PAR’ denials!

Ensure that your billing team is keeping a pulse on those denials at all times. Dedicated billing staff should be consistently working on denials and investigating the causes. If a pattern of denials caused by credentialing error is found, billing staff should communicate this to the credentialing team so action can be taken to correct the issues. Committing to continually track the cause of denials and communicate with your credentialing team is a proactive approach to receiving payments for once denied claims.

Be sure all billing staff understands what the payer is telling you! You received denials from a commercial plan for one of your physicians. Your billing team has contacted the plan to find out the cause. They were informed that the provider is non-par, or not participating. But do they know what this means? It’s possible that the provider has not yet been enrolled with the carrier at all. It could also mean that while the provider is enrolled and linked to your TIN accurately, he has not yet been linked to the location in which the patient was seen. These scenarios are very common when researching the cause of denials. Continuing to educate your billing staff about credentialing related denials and ensuring strong communications between billing and credentialing staff can make a huge impact on your bottom line.

We all know that the devil is in the details and with 1 out of 3 denials stemming from credentialing, it is one detail that you definitely need to pay attention to. In 2018, make it your resolution to ensure your credentialing efforts are on point and watch for the positive effects on your bottom line.