We at PMG Credentialing have never seen an FQHC that is not working tirelessly to maximize 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 performing below expectations. In our experience, the success of an FQHCs revenue cycle requires a solid foundation of proper provider enrollment and credentialing.

Far too often we see CHCs place the burden of payer credentialing on their busy billing or HR departments but navigating the insurance enrollment process is a daunting task and requires highly specialized individuals who understand all aspects of the process.  When mistakes are made, revenue is delayed or lost and, in some cases, those mistakes can expose you to legal liability. 

We have seen our share of credentialing issues over the years, and we’d like to share with you three of the most common and what you can do to help ensure they are corrected.

Relying on an Already Overworked Staff

Credentialing is a labor-intensive process that requires accuracy, attention to detail, and patience. There are a long list of certifications and licenses to verify including the practitioner’s entire employment history, their education, training and licenses, as well as any certifications issued by a board in the provider’s area of specialty. All this information must be verified for every individual healthcare provider who provides services for patients.

Completing the credentialing process for every single individual is an enormous amount of work and data to manage for any individual or team. CHCs often make the mistake of not allocating adequate resources or staff to successfully navigate the medical credentialing process. The result is lost revenue and stressed, overworked staff.

Ensure that you have the internal resources dedicated to provider enrollment. Spend time in hiring a qualified person or people to handle this at your CHC or provide training for existing staff.  If you just cannot find the right person, outsourcing is another viable option.  If you think outsourcing is too cost prohibitive, consider the fact that the ROI for the price of enrollment/payer credentialing service is usually equal to 10-12 paid visits for the newly enrolled provider. In other words, national UDS data shows CHCs make about $177 per visit. Only 10-12 visits paid equals $1,500- $1,800. Therefore, a service costing about this much money pays for itself within 10-12 visits.

Providers Have Not Been Enrolled Correctly with Payers

As we discussed earlier, the average provider enrollment application requires an overwhelming amount of information and data. Failing to fill out the application in its entirety with accuracy causes delays in reimbursement and potentially denied claims.  Sometimes the individuals handling credentialing don't always have a clear idea or timeline of how payer enrollment works. They think they have done everything necessary to allow providers to see patients and they assume they will get paid for those visits.  Instead, they receive multiple denials on those claims resulting in delayed or lost revenue.

As you manage your credentialing process, here are some things to keep in mind to ensure the process runs smoothly:

●        Be sure to submit all supporting documentation required (malpractice, DEA, licenses, supervising information etc.) and make sure all supporting documents are up to date and not expired before submitting.

●        Always follow up in a timely manner to ensure applications have been received and are in process. If possible, you should have a dedicated individual or team to follow up on submitted applications on a weekly basis.

●        At PMG Credentialing, we utilize account managers that have direct and personal contact with payers.  They have knowledge of processing times and rules within the state for CHCs which help to get applications processed in a timely fashion.

●        Establish an escalation process and when payers are not processing applications timely

●        You should have organized reports that show when applications were submitted and the follow up that is being done so you know the status of each application.  These should be reviewed on a regular basis to ensure your credentialing process is working.

Lack of Organization to Keep Enrollments and HRSA Regulation up to Date

Healthcare providers need to renew their licenses and credentials on a regular basis, based on the laws of the state in which they practice. A solid credentialing process ensures that healthcare providers are up to date with their board certifications and licenses. When health centers fail to stay on top of their credentialing, it could lead to providers performing services they are not certified or licensed to perform. The results are delayed or lost revenue, and in a worst-case scenario, legal liability.

It is also critical for FQHCs to keep track of their individual providers and ensure they revalidate or renew their enrollment records on time to maintain Medicare billing privileges.  Failing to do so could result in a hold on your Medicare reimbursement or deactivation of your billing privileges.  If this happens, a complete Medicare enrollment application will need to be re-submitted*.

Based on our experience in provider enrollment and credentialing, here are several critical components you need to make sure your CHC is doing to keep things running smoothly:

●        Keep Medicare information up to date such as EFT information, board member and staff information.

●        Revalidation of providers and locations.

●        Ensure that providers are linked correctly to the Part B enrollment.

●        Assign dedicated account managers/staff members that reviews all provider credentials and communicates well ahead of time when they are going to expire.

●        Have a dedicated team to keep provider CAQH’s up to date to ensure payers are getting the most up to date information. If this is not kept up to date, payers will not enroll or will drop providers.

●        Assign an account manager/staff member to keep complete, up to date files for all providers to send to HRSA during audits.

Keeping these crucial tasks in mind as you build and maintain your credentialing process will help ensure success at your CHC.  Of course, this process can be daunting and time consuming, so it is important to make sure your team has a clear understanding of their roles and responsibilities as well as enough time to complete and manage the tasks at hand. 

PMG Credentialing has been working exclusively with CHCs and FQHCs for many years. We have a dedicated team of account managers who are familiar with your unique needs, the state-specific rules and processing times associated with the credentialing process.  We would be happy to answer any questions or discuss your specific credentialing challenges.  Simply call us at 401-616-2090 or contact us to reach a PMG Credentialing expert.

*https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/Revalidations