Credentialing. There’s no Easy Button for that.

17Staples has its now famous “Easy button” which designates how easy it is to get things done with them. There are countless apps for nearly every process and experience you can think of, adding ease of use and simplification. Then there is physician credentialing. What was once a simpler process that previously included the single step of having the applicant present some form of documentation, such as a diploma or certificate, is now much more complicated.

Multiple forms. Credentialing today requires school, residency and licensing verification directly from the source of the diploma, license, etc. Thorough and legitimate collection and verification of this information is not only important in meeting requirements of main accreditors, but also critical in avoiding legal problems and ensuring quality patient care.

Many people. The lengthy and increasingly complicated process of credentialing requires input from multiple people serving in specific roles. Almost like a set of dominos, if one of these roles is not fulfilled correctly and in a timely manner, the entire process could crumble or cause major headaches.

Myriad steps. From the applicant’s responsibility to provide a clinical facility with supporting paperwork such as degrees, accreditations and licenses, to medical staff’s responsibility to process and maintain the applicant’s credentialing file, there are a lot of steps and paperwork to keep track of. In departmentalized hospitals, the Department Chair also plays an important role in reviewing credentialing files. A credentialing committee, medical executive committee and governing board of directors also play important roles in the process as applicable to the specific facility.

If you’ve been through it just once, you know exactly what I’m talking about. While each hospital and physician’s office have their own individual challenges, a thorough and valid credentialing process is no less imperative. Healthcare facilities can benefit greatly from knowledgeable staff that is thoroughly trained to handle time consuming credentialing process and focus on nothing but making sure it is getting done right. Remove the possibility of one of the “dominos” falling in the credentialing process, and outsource to a company that can cover everything from A to Z. It’s not technically an “Easy Button,” but it’s the easy and obvious solution.

Automate to Collect

Laptop doctorOut of sight, out of mind. Applied to healthcare, this age-old saying is not only true, but also incredibly problematic for physician practices. All too frequently we hear from physicians the same story of providing care up-front, and subsequently facing a growing stack of un-paid deductibles, ultimately hurting the bottom line. No one is immune to this – not general practitioners, specialists, psychologists, nor dentists.

With the trend of increasing deductibles, there is only going to be more to collect. For 2014, the internal revenue service has defined high-deductible as $1250 for an individual and $2500 for a family. On top of that, maximum out-of-pocket expenditures are estimated at $6350 for individuals and $12,700 for families. That’s no small change; that’s real money when factoring in the number of patients you see.

Some practices may have an initial reaction of fear or a sense of alarm from these numbers however, these statistics should be the impetus to be proactive and put the right series of steps and technologies into place. Those steps include implementing a hybrid workflow model that starts with using an established eligibility checking system to identify a patient’s expected out-of-pocket costs prior to an appointment will significantly lessen the follow-up collections that are needed. However, when you do need to collect, make sure you are doing it smartly by leveraging the second piece of a hybrid workflow solution, an automated collection system to significantly increase the odds that you will collect more, and also collect it faster.

Recent highlights from the Pew Research Internet Project state that as of January 2014, 58% of adult Americans have a smartphone.  Doesn’t it make sense then that you should have an automated system that includes texting alerts instead of sending outdated hard copy letters? By replacing traditional collection methods with an automated technology platform that smartly uses decision rules to push out text and secure e-mail, and logs a record of all the activity, you can count your profits instead of counting the number of uncollected deductibles.

Going up! Effectively using eligibility verification as deductibles increase

PricewaterhouseCoopers reported in 2013 that 17 percent of employers were offering high-deductible plans as their only option. That’s a 31 percent increase over 2012. Forty four percent of employers said that high-deductible plans would be their only option in 2014, according to PwC. This rise started in traditional health plans, and with the rollout of the Affordable Care Act, we are seeing more high-deductible plans being offered, and they present quite a challenge to physician practices. In this new environment, practices need to think more like a business so they cannot just survive, but be profitable.

Attributed to the famous Spanish painter Pablo Picasso is the phrase, “action is the foundational key to all success.” For physician practices, that action in regard to the trend of increased deductibles is assuring that it is a priority to operate as an efficient business to collect on these deductibles.

And that proper collection needs to start with eligibility and out-of-network benefits verification that is conducted prior to the patient even arriving for their visit.

Too often we hear stories from practices who cannot recoup the out-of-pocket deductibles after the patient leaves the office, or Overworked tired doctor at computerwho continue to get claims rejected by the insurance companies because the services rendered are not covered under that plan. Sound familiar? So, instead of nodding in regretful agreement, implement a hybrid workflow model that starts with back office expertise in providing eligibility verification.

It is more important than ever to run proper eligibility checks to confirm what plan and coverages the patient has (under ObamaCare alone there are four new types of plans, and each different for individual or family) what the deductible is, and if the deductible has been met yet or not.

Eligibility checking is also the single most effective way of preventing insurance claim denials. We begin with retrieving a list of scheduled appointments and verifying insurance coverage for the patients. Once the verification is done the coverage details are put directly into the appointment scheduler for the office staff’s notification.

At ClinicSpectrum, our services cover the three methods for checking eligibility including online websites and portals; automated voice system (IVR), and directly calling insurance companies to gather more information. And we’ve proven that our methods work.

So focus on care, and let us focus on the eligibility check. Tackling this challenge at the start of a patient encounter will alleviate bigger operational and financial stresses down the road.

High deductible plans: Balancing out-of-pocket costs and outcomes

This post was originally posted on Medical Economics.

ME051014_pg 18In 2013, the U.S. Department of Health and Human Services reported that healthcare spending had grown at a record low pace from 2009 to 2011. The slowdown in  growth was attributed to the sluggish economy and was thought unlikely to continue as more Americans gained insurance under the Affordable Care Act (ACA).

An increase in the spending growth rate was considered inevitable—a 6.1% acceleration was predicted for 2014, compared with a 3.9 % increase in 2011. Even so, there was hope that the consumer-driven belt-tightening that occurred during the recession would continue despite more people being insured.

The way policy analysts expected that to happen was through shifting a larger share of spending to consumers.

High-deductible health plans started appearing after legislation was passed in 2003 that required persons opening a health savings account to enroll in a high-deductible plan. They started gaining prominence in recent years as employers watched their own healthcare spending skyrocket, forcing them to look for ways to shift more of the burden to employees, according to Brett Hickman, CPA, partner in PwC’s health industries practice.

A June 2013 PwC report found that 17% of employers were offering high-deductible plans as their only option, a 31% increase over 2012. The percentage that said high-deductible plans would be the only option in 2014 jumped to 44%, according to PwC.

How high deductibles work
Under a high-deductible plan, in exchange for low monthly premiums plan members must meet higher deductibles before their insurance coverage begins.
For 2014, the internal revenue service’s definition of high-deductible is $1,250 for an individual and $2,500 for a family. Maximum out-of-pocket expenditures are $6,350 and $12,700 for individuals and families, respectively. Many, but not all, include preventive care such as annual physicals or immunizations, as a no-cost benefit.

If high-deductible health plans continue to rise and 50% of the people with employer-provided healthcare plans are covered by them, healthcare spending could be reduced by about 4%, or $57 billion, annually, according to a 2012 study in Health Affairs.

The unknown factor is whether reducing  healthcare spending on the front end will cause unintended consequences later. Under the “gatekeeper” model of care in the 1990s, patients would often forego care from specialists who were, unlike capitated primary care providers, reimbursed using the fee-for-service model that required greater out-of-pocket payments from patients, says Hickman. By putting off care from a specialist, many patients’ conditions deteriorated to the point that they required more care than they would have otherwise, thereby leading to higher costs.

There are many similarities between the model of care prevalent in the 1990s and the one emerging today. How successful the current model will be remains open to debate.

“I think any bean counter or actuary will tell you we are on a slippery slope right now,” says Hickman. “We’ve got to get to organized population health where we can use predictive analytics and we can align the incentives across the patients, providers and the health plans … to ensure the patient gets the right care that he or she needs when they need it and it’s not over- or underutilized.”

The impact on physicians
When patients pay more out-of-pocket, they are generally more judicious about when and under what circumstances they see their doctors, and what tests and procedures they are willing to undergo. Consequently, many healthcare experts have concluded that in a fee-for-service world, physician income will drop as visits decline.

What’s not clear is whether physicians will find ways to offset the financial impact of fewer visits—although some believe the increased number of insured patients entering the system through the ACA will help keep office schedules full—and the impact fewer visits will have on overall care quality.

“Any time you see patients responsible for more of the front-end cost, they don’t go to the doctor as much,” says Bill Hannah, principal of healthcare at the accounting firm  Dixon Hughes Goodman, and a member of the National CPA Health Care Advisors Association. Some patients skipping care might have chronic diseases and require  regular check-ups, Hannah says.

More physicians are joining accountable care organizations, which will have the effect of incentivizing physicians to keep their patients healthy—which means, in turn, that physicians will have to be proactive about ensuring that patients are getting the care they need. As a result, practicing population health will become a necessity.

In addition to fewer visits, practices could face other financial hits as a result of more patient responsibility. The American Medical Association’s annual health insurer report card found that in 2013 patients were responsible for nearly one quarter of total medical bills. This is potentially bad news for medical practices, because collecting from patients can be notoriously difficult. And when patients are faced with financial hardships, medical bills usually don’t take priority.

The National Center for Health Statistics published a report in January, 2014 that found one in four families experienced trouble paying medical bills in 2012. One in 10 had bills they were unable to pay at all. At the every least, practices can expect to see the length of time invoices spend in accounts receivable to grow.

What physicians can do
The new reality for physicians is that they will be forced to have more conversations with patients about the cost of care, says Thomas Graf, MD, chief medical officer for population health at Geisinger Health System. And they will be forced to think about the financial implications of every decision they make, adds Graf, who directs the ProvenHealth Navigator, Geisinger’s medical home.

“There are times when we may be, let’s say, overly complete in the evaluation and a more stepwise approach may be more prudent,” Graf says. “So rather than ordering all the tests the first time you see the patient, perhaps you start with the most likely elements and work to the less frequent causes of it in an effort to support the patient in their desire to limit their out-of-pocket expense.”

Patient education also needs to improve. Patients often think that the newest or most expensive treatment is the best option when it actually might be bed rest, says Mark Bogen, chief financial officer and senior vice president of finance at South Nassau Communities Hospital in New York.

“Some physicians aren’t real excited about having to lay out what the cost of everything is,” says Sherri Sellmeyer, vice president of advisory services at Decision Resources Group, a healthcare research and consulting firm in Burlington, Massachusetts “I think it’s probably a healthy thing for the system for people to know what things cost.”

Research presented at the 2013 meeting of the American Society of Clinical Oncology by S. Yousuf Zafar, MD, MHS, a gastrointestinal oncologist at the Duke University Health System in Durham, North Carolina, showed that a majority of cancer patients think it’s important to talk to their physicians about treatment costs. But only a small percentage actually have that conversation because they fear that bringing it up will lead to the doctor prescribing a cheaper option, which in their minds is inferior. But the researchers found that  when the conversation does happen, the cost of care is generally lower.

Now that patients are paying more out-of-pocket, these conversations may become easier. Graf says he has noticed that patients in high-deductible plans are “suddenly much more interested in my explanation about why they don’t need a CT [computerized tomography] scan than they would have been in the old days when in some situations you could talk for 10 to 15 minutes, knowing the chance of the CT scan showing anything real is all but zero. But they were so worried about it that they sort of insisted on getting that done.”

Employers should take the lead when it comes to talking to employees about how their health plans work, Hannah says. “Call it healthcare economics 101,” he says.

“Employers have an obligation to educate employees on costs and how to promote better health.”

Think like a business
In this new environment, practices will also be forced to think more like a business. Because a large portion of the medical bill has traditionally been paid by commercial insurers, Medicare, and other third-party payers, many practices simply aren’t set up to  collect copayments from patients efficiently. Many small practices, for example, still don’t accept credit cards or have an online payment system, says Bogen. Even worse, when the patient tells the practice that he or she will pay next time, practices aren’t following up to ensure that the patient actually does pay.

Many physicians don’t want to discuss payments out of concern that patients will  think it’s all about the money, says Bogen. Physicians can still offer some flexibility while maintaining the attitude that they are entitled to be paid for services rendered, he says. “When you combine the cost shift of these high-deductible plans with the shrinking payments that the commercial insurers and Medicare are already moving toward, you have to collect every nickel you are entitled to,” Bogen advises. “They shouldn’t feel ashamed they are asking to be paid.”

Many studies have found that practices are more likely to be paid if they collect before or at the time of service. This may mean investing in upgraded revenue cycle management systems that can check eligibility, tell the practice whether the deductible has been met, and calculate the patient portion before the appointment.

It’s likely that practices will start issuing refunds as their collection practices change, says Laura Palmer, FACMPE, senior industry analyst for the Medical Group Management Association. It’s not uncommon for practices to run an eligibility check that shows the deductible has not been met. But that situation may change sometime between the appointment and the time the bill is sent. Practices need to establish policies for how the patient will be refunded for an overpayment.

A practice’s billing policy should also include a process addressing the situation of patients who have trouble paying, and a menu of options that can be presented to the patient, says Palmer. Options may include community programs that assist with medical bills, or referrals to facilities that offer free or significantly reduced care costs.  Options may vary depending on the patient’s circumstances, which the practice should make every effort to understand, she says. There’s a difference between someone who is refusing to pay and someone who simply cannot.

The policy should also detail who in the practice will talk to the patient and where that discussion will take place. Palmer says conversations about overdue bills or a patient’s inability to pay should never take place at the front desk. The conversation should be held in private.
If all other efforts to collect from the patient have been exhausted, physicians can terminate their relationship with them, says Graf. But that option should be reserved as an absolute last resort, and it must be handled delicately. Patients should be given ample warning, and they must be referred to another care provider.

This new world of high-deductible heath plans can produce the intended results as long as incentives are aligned for all stakeholders, says Graf. He tells physicians to gain an understanding of their relationship with each insurer, and their patients’ relationships with the insurers. Physicians should try to “set up a system where the patient can win, I can win and the health plan can win,” he says. “If you can find that middle ground, which is often challenging, but if you can find it then you are going to do really well. Probably better than if you are stuck in a situation where in order for you to win, someone else has to lose.”

See more at:

Red flags in the credentialing process

When I think of a process, I think of clear steps that one follows to consistently achieve the same end result. Whether it’s the Blog-Red-Flag1process for making cookies, mailing a package, or boarding a plan, there is a series of events that are followed and at the end we reach the same result each time.  For credentialing,  however, the  process is not as clear cut. There are many nuances and details, not to mention changes in healthcare policies that can make even the most diligent healthcare management professional have a slipup. But, unlike resulting in a soggy or over-crunchy batch of cookies, a slip-up in credentialing is far more serious.

While this isn’t fully encompassing, there are some “red flags” of the physician credentialing process that can be invaluable to know and keep an eye out for.

Certain indicators that can raise concern include:

  • Gaps in time between residencies, employment or training that are not explained or verified
  • Mismatched or missing information between the application and CV
  • Professional references that are vague, missing needed information or in any way negative

While these indicators do not account for all red flags that should be investigated prior to making a recommendation regarding appointment or clinical privileges, they are certainly some of the most predominant and frequently seen.

To take the safety and assured accuracy of your credentialing one step further, and to hopefully avoid these red flags, consider working with a vendor to handle the process for you.

Qualified, knowledgeable staff, and technology offerings are available to help with credentialing assignments. Expert vendors can offer tools that give you credential expiration reminders, templates for applications, task management and milestones to lead you through the process; all for easy workflow management.

Putting this important task in the hands of subject matter- experts can help alleviate the risk and save office staff time to focus on other equally important day-to-day business operations.

Credentialing is complicated

Credentialing is not only time-intensive, it is complicated and confusing. What are the steps? Do you have all the documentation? Have the regulations for credentialing changed again? It’s enough to make your head spin, and, of course, there is too much at risk to let the process to be anything less than absolutely perfect.

Successful credentialing requires complete, attentive assessment and knowledgeable staff versed on the ins-and-outs of the extensive and complicated requirements. To break it down, there are generally two tiers of the credentialing and privileging process. Tier one includes verification or primary credentials and competence, including the steps between application, verification of credentials, evaluation of core competencies and a Focused Professional Practice Evaluation (FPPE) if the physician applicant lacks competency documentation.

Tier two includes delineation of privileges, appointment and reappointment. This tier can include six steps even more complex than those in tier two with the involvement of evidence-based methodologies, credentials committees and executives committees.

It should come as no surprise that credential applications frequently have errors or cause major headaches for hospital and physician practice staff –to no fault of their own, other than simply not having the time or experience to complete the process seamlessly.

The solution? Many times working with an outside source can be the best option for credentialing physicians. Relying on a knowledgeable vendor who is not only devoting the time and dedicated staff, but who is also taking on the responsibility for assuring the accuracy of credentialing, can save your hospital or practice valuable time, resources and money that can otherwise be devoted elsewhere.  While credentialing is no less important than scheduling, for example, it offers an incredible, special challenge requiring time and know-how.

Automated Billing: Increase Time with Patients, Practice Profitability

Physician practices are very aware of the growing amount of deductible collection that will be necessary with the huge influx of eligible patients under the Affordable Care Act. But while they are very aware, this doesn’t necessarily mean they have measures set up to best prepare for this influx. If they have set preparatory measures, are those measures helping to simplify processes and work flow, or is there now just more work to be done?

Eligibility All of the physicians I work with go into practice to help and heal people. They didn’t study medicine to then explore the ins and outs of all things payer, billing, and appointment reminders. For those with smaller practices, they and maybe one other clinical staff member are multitasking; handling everything from diagnosis to accounts receivable follow-up, and even eligibility verification. Add back- and front-office operations to that and you’ve got a formula for loss in revenue and harried business operations. Some of the most prevalent and common issues I see physicians’ practices face include:

  •  Increased cost in overall operations
  • Reimbursements and revenues decreasing
  • High deductibles or increased patient deductibles
  • Delays in collection of deductibles and other balances due to billing inaccuracies
  • Employee compensation increases
  • Overall inflation of business operation costs
  • Confusion about healthcare reform specifications for small- to mid-sized practices
  • Failure or lag in communications through traditional phone calls and mailed letters

But there is a better way: Automating billing and collection systems that will maximize profitability and increase time with patients. While undoubtedly there will be skepticism from some physicians after a decade of the failed promises of enhanced productivity and improved care from many EHRs and other systems, automated billing can be done, and at a cost that won’t elicit sticker shock. You can:

  • Streamline collection methods. This can often be a bane for back-office operations to say the least. Manual collections often result in massive amounts of paper records, hard copy mailings, and staff hours following up with patients on balances owed. Your office staff should be welcoming patients and becoming more involved in their care to help keep them with the practice; not manually dialing phone number after phone number so you can get dollars in the door. Additionally, just because you have the staff to do the office work, doesn’t necessarily mean that work is done cost-effectively and successfully.
  • Increase/better target use of communication such as secure text, e-mail, and phone calls. Similar to my above point, free up your back-office operations to do the most important things for your practice. By targeting communication channels specific to your patients’ likes and needs, you streamline your practice operations. You aren’t hard-copy mailing a young patient who only responds to text messages. You aren’t e-mailing a patient who checks e-mail once every month.
  • Report non-responsive debtors to credit bureaus and/or legal departments to take the workload off of the practice staff. By automating processes, your staff isn’t bogged down by work when people don’t pay. There are solutions to freeing up their time and making sure your practice profits.

Here’s an example that might apply to your practice: Take a look at your eligibility verification. If each claim denial costs your practice $25 to $30, and you know your denial rate is above the industry average of 3 percent, the monthly cost for eligibility verification in advance of patient visits shows an outsourcing company with this specialty effectively pays for itself. As a patient, and with friends and family who are patients, I want to know that when I see the doctor that he is able to be clear minded and exclusively focused on my care or the care of my family member. With automated billing solutions in place, physicians can focus on the practice of medicine, freeing their time to focus on patient care, and work with their office staff to maximize profitability. Vishal Gandhi is chief executive officer of ClinicSpectrum, leaders in hybrid work flow solutions consisting of both an innovative software suite and back-office operations. E-mail him here. See more at:

Credentialing Issues and Resolution

Credentialing Issues and ResolutionWhile it’s imperative that each and every physician is properly vetted and credentialed prior to practicing for numerous reasons, the tedium that goes into the process can steal valuable time away from patient care, scheduling and billing – also tasks incredibly important to overall business operations. Compound all of this with the explosion of credentialing requirements and paperwork, staff can take up to 3-5 hours each day on credentialing.

Today’s healthcare industry offers numerous challenges that lend to strapped staff time. Requirements for hospitals and healthcare organizations continue to grow with Meaningful Use and HIPAA. As of January 2013, only credentialed medical assistants have been permitted to enter medication, radiology, and laboratory orders into the EHR to count toward meeting the Meaningful Use thresholds under the Medicare and Medicaid EHR Incentive programs.

With the growing complications and tediousness of credentialing, the risk of error exists, and the ramifications of incorrect or insufficient credentialing can cost practices and hospitals dearly. Payer processes can be slowed, patient-risk is increased and organizations can pay hefty fines in malpractice situations if proper paperwork is not produced.

A resolution? To best manage this oftentimes complicated task of physician credentialing, practices and hospitals can look to vendors well-versed in the space that can securely manage the process for credentialing and re-credentialing. Vendors should have the ability to manage profiles and documents for physicians, help monitor for expiring credentials and have a dedicated, knowledgeable staff to answer any questions about the process in general. Save time, save money, save the legal headaches.