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Training Session HandoutsCredentialing andEnrollment 101Master the Complexities of Getting Your ProvidersApproved More Quickly & AccuratelyPresented by:Tracey Tokheim

[DISCLAIMER] Training Leader. This 2019 Webinar Handout is published by Training Leader, adivision of Must Have Info, Inc. Reproduction or further distribution by any means,beyond the paid customer, is strictly forbidden without written consent of TrainingLeader, including photocopying and digital, electronic, and/or Web distribution,dissemination, storage, or retrieval.This webinar is an independent product of Training Leader. It is not endorsed by norhas it any official connection with any other organization, insurance carrier, vendor, orcompany. Reasonable attempts have been made to provide accuracy in the content.However, of necessity, examples cited and advice given in a national periodical such asthis must be general in nature and may not apply to any particular case. The publisher,editors, board members, contributors, nor consultants warrant or guarantee that theinformation contained herein on coding or compliance will be applicable or appropriatein any particular situation.(c) 2019 Must Have Info, Inc. All Rights Reserved.Training Leader, 2277 Trade Center Way, Suite 101,Naples, FL 34109, Phone: 800-767-1181 Fax: 800767-9706 E-mail: info@trainingleader.com Website:www.hctrainingleader.com

Credentialing 101 For Your PracticeProvider Enrollment 101Changing & How to Keep Up to SpeedPresenter: Tracey TokheimAGENDA Definitions Who is Enrolled? Information Needed to Enroll Polling Questions Barriers to Successful Enrollment Keys to Success Educational Organizations What is Delegation Barriers to Data Integrity – Managing multiple data sources Establish a successful process for obtaining information Application Process Application Process Tools Provider Enrollment Activity Tracking2www.trainingleader.comProprietary & Confidential1

Credentialing 101 For Your PracticeAGENDA (cont’d) Tools for Tracking the Moving Parts/Pieces Must Knows about Application Completion Application Review Application Reg Flags Software Solutions–––––PECOSHealthStream (OneApp, Morrissey)CactusCAQHMicrosoft using Access/Excel Review of Polling Question Results References Contact Information Q & A3Proprietary & ConfidentialDefinition and Differences betweenProvider Enrollment andCredentialing/Privileging Credentialing/Privileging Definition Provider Enrollment DefinitionThe application process by which apractitioner is approved to seekreimbursement from government and/orthird party payers OR seek admittingprivileges at a hospitalIs the process of obtaining, verifying andassessing the qualifications of ahealthcare practitioner to providepatient care services in or for ahealthcare entity.Privileging is the process by whichauthorization is granted by a hospital toa practitioner to provide specific patientcare service in a hospital.4www.trainingleader.comProprietary & Confidential2

Credentialing 101 For Your PracticeWho is Enrolled? Independent Practitioners: licensed by the state and allowedto practice independently (e.g., Physician) Dependent Practitioners: able to provide care under thedirection or supervision of a medical staff member For health plan enrollment, typically it is a process forproviders who bill for professional services under theirown name. There may be exception to this rule. For hospital enrollment, typically it is a process to obtainhospital admitting privileges.Facilities: A building or structure in order to bill a technical fee.Proprietary & ConfidentialWhat information is needed?Application ElementsApplication ElementsPersonal Demographic InformationEducationTraining InformationCredentialing Contact InformationHospital Affiliation(s)Work HistoryGaps (e.g. education, work)Reference InformationLiability InsuranceLiability Case InformationImages of DocumentsAdditional DocumentsPrivilege InformationCredentialing Contact InformationOffice Location Information(including TIN & NPI)ID Numbers (NPI, DriverLicense/State ID)Proprietary & Confidentialwww.trainingleader.com3

Credentialing 101 For Your PracticePolling Question1. How do you keep up to speed on all of thechanges?A. Local GroupB. National Membership/NAMSSC. NewslettersD. Colleagues/PeersProprietary & ConfidentialPolling Question1. What is your top frustration in beingsuccessful with Provider Enrollment?A. Keeping current on forms/processB. Time it takes to get an approvalC. Manual vs. Automated or SystemD. Have other role(s)/Not enough timeE. Internal SupportProprietary & Confidentialwww.trainingleader.com4

Credentialing 101 For Your PracticeBarriers to Successful ProviderEnrollment Changing Industry – continuous learning Enrollment process (forms) Requirements Timing for completion Many moving parts and tracking/prioritization High staff turnover Application volume not balanced Lack of support or knowledge within yourorganizationProprietary & ConfidentialKey to Success Educate providers and your organization to understand theimportance of provider enrollment and the impacts it has on revenue Get commitment from the TOP down in your organization to adopt astreamline process with commitment to continued review Establishing a process for obtaining the relevant information for eachplan/hospital Obtain all information the FIRST TIME and as quick as possible Create and maintain connections with the plans/hospitalsBe organized to track all the moving pieces so nothing falls throughthe cracksMentor new people to help them be successful. Give backProprietary & Confidentialwww.trainingleader.com5

Credentialing 101 For Your Practice Educational OrganizationsNAMSS – www.NAMSS.orgState Medical Staff Services entitiesPeer GroupsPayer Newsletters or Websites CMS – www.CMS.govState MedicaidPayersProprietary & ConfidentialWhat is Delegation?A formal process by which theorganization gives another entity theauthority to perform certain functionson its behalf. Although the organizationmay delegate the authority to perform afunction, it may not delegateresponsibility for ensuring that thefunction is performed appropriately.Proprietary & Confidentialwww.trainingleader.com6

Credentialing 101 For Your PracticeSteps to Becoming Delegated Evaluate the delegation agreement Make sure it contains all of the required elements forcompliance Make sure it’s mutually agreed upon Ensure all responsibilities are outlined in detail Has to include at minimum semi‐annual audits Determine the process and handoffs through the completeprocess Identify any remedies if all obligations do not occurConstruct a delegation agreementIdentify a pre‐delegation evaluation processDefine delegation oversight/annual audit processEvaluate reportingApproval of final reporting outcomesProprietary & ConfidentialPolling Question 33. With the new Directory Managementrequirements, do you think your data isaccurate? Also, do you have a process?a. Yesb. NoProprietary & Confidentialwww.trainingleader.com7

Credentialing 101 For Your PracticeBarriers to Data Integrity – Managingmultiple data sources Solid identification of data movement to source(s)Adoption of who’s data is correct (dataintegrity)2 Directional Data MovementLimitation of different technology/languagebarriersExpertise outside of the EnrollmentDepartment needed (IT constraints)Proprietary & ConfidentialTools for Tracking the MovingParts/Pieces Software programs which includetrigger or task notification Spreadsheets Reminders on your calendarProprietary & Confidentialwww.trainingleader.com8

Credentialing 101 For Your PracticeKeys to Success Communication Internal External Process – review and revise Knowledge is KEY Create a toolbox because not every execution of aprocess works the same Review and REVISE REPEATProprietary & ConfidentialEstablish A Successful Process forobtaining all Information Create a communication plan between you, the provider, and any otherparty involved directly or indirectly in this process. Communicate from the beginning the information needed, expectationsand time lines; and the reason why you need this information. Create a process internally and externally to identify each member ofthe teams roles and responsibilities. Make sure the requirements for each plan or hospital includingapplications, additional documents, and accepted submissions optionsare clearly defined and understood. Required for Success: PERIODICALLY REVIEW THE PROCESS THEASK FOR FEEDBACK TO BETTER THE EXPERIENCE.Proprietary & Confidentialwww.trainingleader.com9

Credentialing 101 For Your PracticeProvider Enrollment ActivityTracking Create a system that allows you to track where the application is at inthe process and use a “Next Due Date” system to make sure thingsdon’t fall through the cracks. Create a system that all staff know and have access to.Create a system to ensure providers understand the importance of fastresponses and expectations. Work your executive leadership to provide ongoing education andawareness of the importance of provider enrollmentCreate a system that all staff knows and has access to.Proprietary & ConfidentialApplication Process Application doesn’t mean paper any longer!!! Need to define clear hand-offsPrepare your process for both paper and electronic databaseapplication processes.Define a process to track and manage recred due datesExpirables ManagementOther enrollment functions Meaning UseDirectory ManagementProprietary & Confidentialwww.trainingleader.com10

Credentialing 101 For Your PracticeApplication Process ToolsProprietary & ConfidentialProprietary & Confidentialwww.trainingleader.com11

Credentialing 101 For Your PracticeSoftware Solutions ApertureECHO (HealthStream) formerly SyMedMorrissey (now HealthStream)SymphrCactusVistarCredSimpleHome grown systemsOther solutionsPaperPECOS (Medicare’s own system)CAQH Changing quickly in this industry .Proprietary & ConfidentialMust Knows about ApplicationCompletion Make sure the information is accurate and clearly identified to deemthe application is complete or if additional information is needed. Document process and time line expectations to organization andprovider Provider needs to include three references for hospitalcredentialing/privileging. One reference should be someone who has personal knowledge ofcurrent clinical skills, observation of work, and ability to workcooperatively with others Another reference should be a professional peer reference from apractitioner in the same specialty Another reference should be someone who has recently beenresponsible for the applicant’s practice at a healthcareorganization (department/section chair, chief of staff, etc.)Proprietary & Confidentialwww.trainingleader.com12

Credentialing 101 For Your PracticeApplication Review Make sure all gaps in time frames are explained Discrepancies in Information – Application/CV/VerifiedInformation – Inconsistent answers – Discrepancies betweenapplication and primary source Large number of malpractice cases and frequent movesReview for missing information/unanswered questionsAll Yes Affirmative Answers to Disciplinary Questions need to beexplainedVague references – may refuse to complete evaluationCancellation or denial of liability coverageInformation from the NPDB does not match applicationinformationProprietary & ConfidentialApplication Red Flags Missing Dates/Gaps in PracticeInterruption of Training ProgramsChange in Hospital Staff CategoryDiscipline by Licensing EntityFrequent MovesVoluntary Resignation Under Threat of DisciplineLiability Coverage CancelledMalpractice ClaimsProprietary & Confidentialwww.trainingleader.com13