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Learn MoreHealthStream regularly publishes guest blog posts like the one below from VerityStream.
This blog post is based on the webinar that features Penny Noyes, President, Founder, and CEO of Health Business Navigators and Dawn Anderson, PESC, CPMSM; Senior Client Success Manager; VerityStream.
In healthcare credentialing, there’s confusion about what it means to be a “participating” provider, which is key to avoiding claim denials. How to ensure providers are participating was the focus of a recent VerityStream webinar presented by Penny Noyes, President, CEO, and Founder of Health Business Navigators. She has over 40 years of experience on the payer and provider side and is known for her practical, methodical approach to contracting and credentialing,
Five Key Things to Know About Credentialing and Participation
Noyes offered five strategies to help get to the bottom of why participation status may be causing claim denials:
Understand exactly what “participating” or “PAR” means.
PAR (or participating) for a provider means that from the standpoint of a payer you are credentialed, contracted, and linked to the tax ID, the group NPI, the contracts, and the products. However, if you call for verification, the person on the other end of the phone may not be well-versed in the nuances of this status, so it is up to you to get a really straight answer from the payer. Not being PAR can be a result of not being credentialed, not being linked to a contract, or not being linked to a specific payer product, among many additional issues.
Use techniques that connect credentialing and “PAR” status with all contracted payers and products.
Noyes recommends cataloging all contracts with payers and identify the products involved in them. In their contracts many payers will use a generic name like PPO, HMO or “All Payers,” creating confusion about what is marketed as, for example, Blue Elites, Blue Select,etc. Ask your payer contracting reps to clarify all the names of the products involved in the contract. Focus on those details.
Ask specific questions to payers when researching gaps in PAR coverage.
Noyes advises use of a spreadsheet listing every provider with a field for every payer to identify any PAR issues. After asking whether a provider is credentialed, follow-up questions about whether he or she is linked to a contract, Tax ID, dates when effective, and to which specific payer products should follow. If the answer to any of these items is no, find out what’s needed to make it yes. Some important additional questions to ask are:
Navigate delegated credentialing situations.
Determine whether provider credentialing has occurred through a delegated situation. An example is new providers who came from a group in the same market had delegated credentialing through a big hospital system. Noyes advises the use of direct credentialing to get them added to your group, linked, and PAR to make sure that you don’t run into the problem two or three months later when the previous employer belatedly terminates them. If you delegated your credentialing to an Independent Practice Association (IPA) or a Physician Hospital Organization (PHO), determine which payers and specific plans your providers have opted into. Most IPAs and PHOs have contracts with 5-10 payers and you complete a form for each specifically. Be certain that these groups include all the products you need and identify the effective dates.
Understand how state laws impact government and commercial plans.
Most states do not have laws regarding payer credentialing. Some of them might indicate a timeframe in which a clean application must be reviewed and approved but typically there's no reference to timeframe for linking. No laws involve fines for failure to credential and link by a certain date, which would make payers pay more attention. Noyes singles out Tennessee’s law, stronger than most, which only applies to group commercial agreements and not government plans or individual agreements. The law requires notification for missing info, establishes a limit on how many days to respond, and sets a 90 day timeframe for complete processing. Regardless, Noyes emphasizes the importance of keeping online plan provider directories updated; state laws are sometimes more stringent than CMS regulations in their requirements for accuracy of information.
Ultimately, Noyes advised that the strategies above can help healthcare organizations improve their financial picture by avoiding and fixing the impact of denials and lower out-of-network care payments. Research, perseverance, and diligence are key, as is keeping detailed notes and closely examining transaction and submission reports for clues to PAR issues. Importantly, for managing more than a handful of providers, she also recommended using a tracking and workflow system like CredentialStream to keep track of every step in the credentialing process.
HealthStream’s learning management system and comprehensive suite of competency management tools empower your healthcare workforce to deliver the best patient care.
View All Learning & PerformanceHealthStream offers performance learning management solutions to help develop your healthcare staff into leaders and reduce turnover.
View All ProductsHealthStream works with healthcare organizations to create engaging and high-quality training videos for your staff and management.
View All ProductsImprove care quality and save money by making informed decisions about your healthcare facility and staff with HealthStream's reporting analytics solution.
View All ProductsHealthStream's proven methods for the improvement and overall engagement of your healthcare staff foster a positive workplace and increase retention rates.
View All ProductsWhen you enact HealthStream's quality compliance solutions, you can do so with the confidence your healthcare organization will meet all standards of care.
View All Quality & ComplianceBe confident in your staff’s ability to reduce risk by providing compliance training that changes behavior.
View All ProductsDevelop next-level people for next-level care by prioritizing quality and safety improvements.
View All ProductsStandardize policy and procedure management with an automated, customized, and centralized system.
View All ProductsEstablish a culture of belonging with education supporting DEI, wellness, engagement, and leadership development.
View All ProductsHealthStream offers professional training and education on how to best optimize your reimbursement process within your healthcare organization.
View All ReimbursementStreamline the revenue cycle management process and protect your bottom line with expert-backed education.
View All ProductsLearn about our advanced resuscitation training solutions. Our solutions are designed to help improve patient outcomes.
View All ResuscitationIn all areas of resuscitation, from neonatal to elderly care, clinical deterioration is a risk that can be avoided with the help of HealthStream's training programs.
View All ProductsNurture the skills of your nurses and medical staff to help mold them into effective leaders with development training from HealthStream.
View All ProductsExpand the decision-making skills and effectiveness of your healthcare workforce with HealthStream's clinical development programs and services.
View All Clinical DevelopmentMake sure your clinicians have the support they need to provide competent care with clinical competency training and development from HealthStream.
View All ProductsHealthStream’s learning management system and comprehensive suite of competency management tools empower your healthcare workforce to deliver the best patient care.
View All ProductsThe suite of healthcare onboarding solutions available from HealthStream aids in nurse retention and improved patient outcomes.
View All ProductsGive your healthcare staff the decision support and skills training they need with the online products available from HealthStream.
View All ProductsHealthStream leverages medical professional development in healthcare by providing staff training programs
View All ProductsMake sure your healthcare staff can schedule out appointments and work schedules with ease using HealthStream's line of software solutions.
View All SchedulingHealthcare workforce management is essential. We provide advanced scheduling solutions for organizations to solve issues such as nurse retention
View All ProductsComprehensive, industry-leading provider onboarding and credentialing software that validate health outcomes and support provider assessment.
View All CredentialingOur affordable CVO credentialing services establish patient safety by enabling primary source verification for your healthcare organization.
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