How Hybrid Workflow Changed Our Practice: 10 Questions with Practice Administrator Nelly Gamboa

Credentialing ServicesClinicSpectrum: How long have you been using ClinicSpectrum?

Nelly: Union County Cardiology has been using the full suite for about 10 years now. We began using billing services and expanded the relationship to use credentialing and billing services.

CS: What do you like the most?

N:  That’s easy. I enjoy that I don’t even have to think about eligibility—all of our patients are confirmed to have insurance prior to their appointment, which considerably cuts down on A/R follow-up and denials management. My monthly headaches have been greatly reduced!

CS: What was the key factor to your decision to implement CS solutions?

N: Time is incredibly important. Saving time means getting paid and settling claims faster, allowing us more time to work on the most important part of the business, our patients. Anything that is proven to save me time is a winner in my book.

When we were doing entire process ourselves time was 30 minutes and cost was $8 to 10 per claim. With ClinicSpectrum, the cost of denials came down to $4 to $5 per claim.

CS: What are the 3 biggest challenges faced by physician’s practices?

N: While I wouldn’t have stayed in this career for so long if I truly didn’t enjoy, the fact is, like with any company, there are daily challenges that the team running a practice faces. From my perspective, I’d have to say that the three biggest challenges are managing efficient operations, staying up to date with all the changes necessitated by healthcare reform, and lastly, and in part linked to the changes in healthcare reform, is managing patient eligibility.

The good news is that there are solutions that greatly aid us in addressing these challenges. ClinicSpectrum’s hybrid workflow model lends itself to efficient operations, by coupling automation and outsourced human follow-up, allowing us to make the highest profit. At the same time, it’s my responsibility to be informed of all reform changes, which can affect every part of our business.

Profitability is hugely determined by adherence to the frequent healthcare reform mandates, so it’s imperative that someone in my position remains aware of all changes.

With automated eligibility, ClinicSpectrum saved us lot of surprises.

For example, eligibility has become a huge challenge due to healthcare reform. An influx of eligible patients, in addition to changes in health plan coverage for patients that were already insured, has left many practices scrambling. Knowing that a patient’s eligibility has been confirmed in advance allows us to secure payment easily and transparently.

CS: What has been the biggest aid for you in tackling these challenges?

N: By switching to automated eligibility verification, we save an average of $3,700 per year, per physician, and by submitting electronic claims rather than paper claims, we save an average of $23,126 per year, per physician, which helps us to still turn a profit and manage efficient operations.

Outsourcing claims and eligibility work is also a huge help in taking on these challenges. My team is able to oversee operations without having to spend the time to do the paperwork and follow-up as well.

CS: What were you looking for in an outsourcing company?

N: We had a few ideal attributes in mind when we began the search for an outsourcing company. We needed a company that could handle claims, authorizations and eligibility—we didn’t want to work with multiple vendors, so instead sought a one-stop-shop. Making sure the company is accountable and accessible is also a factor. Claims processing is often a 24/7 endeavor and I wanted to work with a company that I knew would take my calls and emails in a timely manner. Lastly, ClinicSpectrum’s hybrid workflow model of both automated and outsourced human follow-up offered something that its competitors didn’t deliver.

ClinicSpectrum offers all of these services and scrubs up the claims so minimal interaction is needed by my administrative staff, which allows us to spend valuable time with patients that would have otherwise been spent on administrative work.

CS: What are some challenges of outsourcing?

N: Our patient’s privacy is of the utmost importance to us and outsourcing can put that at risk. We prioritize that our patient data is safe and secure and that the company we outsource to remains HIPAA compliant.

Nelly Gamboa is administrator for Union County Cardiology Associates in Union, N.J.

How to create a delegated credentialing program?

Credentialing Services

This is part two of a two-part post that evaluates what is delegated credentialing and why healthcare provider organizations should consider it.

As explained in the first post of this two-part series, delegated credentialing is an opportunity for large provider organizations to take matters into their own hands, streamline processes and realize substantial benefits. These include getting providers credentialed quicker so they can generate revenue and expand clinical bandwidth.

So, how do organizations create a delegated credentialing services process? It entails establishing processes, as well as implementing tools to assist with workflow and manage the flow of data.

Key processes to implement include:

  • Adopting Credentialing Standards — The National Committee for Quality Assurance (NCQA) has already established standards for payers, as has the Joint Commission for providers. Standards from both organizations should be adopted, as well as any specific standards from regional payers.
  • Establish a Review Process — Create a committee to define processes and review provider credentialing.
  • Conduct Ongoing Monitor — Develop processes to continually monitor work quality.
  • Re-Credentialing — Create processes to easily re-credential providers on an ongoing basis.
  • Create Agreements with Payers — Delegated credentialing agreements need to be established, clearly stating structure and metrics, including:
    • Outlining the responsibilities of the payer and delegated entity.
    • Detailing metrics of how the payer can define and assess performance.
    • Developing ongoing oversight processes.

Accomplishing these processes requires sophisticated credentialing software that includes:

  • Analytics and reporting
  • Dashboard presentations and milestone tracking
  • Demographic import features
  • Document management
  • Reminders and notifications
  • Task management and assignment features

A key resource to assist with delegated credentialing programs is the Healthcare Billing and Management Association (HBMA). The organization has a number of useful resources that expound on the above in further detail.

Author Julia Solooki is a board member of the HBMA Education Committee.

Credentialing Dashboards Part 2 – Additional Capabilities to Evaluate  

Last week we wrote a brief overview of credentialing dashboards and several people contacted us with questions about additional dashboard capabilities. To address some of those questions, we’re highlighting some other important dashboard capabilities in this week’s post. Below are several key capabilities to look for when evaluating the dashboard components of credentialing solutions.

Milestones — Dashboards also need to display progress toward, or the completion of, key milestones so users can view specific activities within the credentialing process. This enables users to quickly know what’s completed, needs to be done, is past due, and what are the new tasks that are entering the process.

Drill-Down Capabilities — An overview status of processes is valuable, but users typically need more information. Drill-down capabilities allow users to click on elements of the dashboard to display specifics, whether it’s information about individual providers, payers, or other elements of the process. This enables users to efficiently get the information they need within one or two clicks.

The Ability to View Tasks and Processes from Different Perspectives — Not all users of the dashboard are looking for the same type of information. Some may be interested in looking payer-specific details, while others are more focused on working on tasks related to individual providers. The dashboard needs to accommodate these perspectives in its display to improve staff efficiency and improved workflow. For example:

  • Payer Information — Sections of the dashboard should display payer-related information, such as payer contact details, insurance PDF forms specific to the payer, web links, as well as counts of providers with insurance and their credentialing status.
  • Provider Information — Other sections of the dashboard need to display provider-specific information, such as the number of providers being credentialed and the status of specific tasks within the process. Drill-down capabilities within the section of the dashboard should enable the viewing of details, including in-depth provider profiles that include all credentialing-related information, as well as the wealth of information imported from the Council for Affordable Quality Healthcare (CAQH).

Specialized Capabilities — It’s important for dashboards to be user friendly and include features that make it easier for the staff to complete their jobs. Leading credentialing solutions include advanced features such as the ability to easily attach documents to records within screens, and capabilities to upload information from other data sources (e.g., CAQH and others). These capabilities reduce data entry, and make documents easier to find.

With dashboards, everyone remains on the same page and is up-to-date with the status of tasks, which increases the efficiency and effectiveness of the credentialing process.

Credentialing Dashboards Keep Staffs on Task, Better Communicate Status

Credentialing Services

Dashboards. To some, the concept is met with open minds and eagerness to view the data in a snapshot. To others, the term conjures up a notion of marketing spin. Can anything really be that great? The answer is yes. If done well, dashboards can not only brilliantly communicate key data to your staff, but keep everyone on task and efficient.

When looking at physician credentialing, communications are a vital part of the process, as everyone needs to know the status of tasks—what’s in progress and what remains to be completed. This information needs to be shared among various stakeholders, such as the credentialing staff, providers, practice administrators, and others. For credentialing, communicating this information is vital to practice operations, reducing risk, and ensuring that providers are eligible to receive reimbursement for their work.

Using a credentialing software solution with a dashboard display is an ideal way to share this information in a format that is easily digestible so information becomes actionable. Dashboards are a graphic representation displaying an up-to-date snapshot of tasks, whether they’re newly assigned, in progress, on hold, or past due. A credentialing system dashboard should be easily accessed, and provide an overview snapshot, milestones, drill-down capabilities, and the ability to view tasks and processes from different perspectives. Here’s a look at the first two of these.

Easily Accessed — When users open the credentialing system, the first thing they should see is the dashboard display. This quickly communicates the status of tasks, and alerts them to issues that need resolving. The easy accessibility of the dashboard eliminates the need for users to click through menus to view the information. It also decreases the chances that important information will get ignored, overlooked or simply not communicated.

Overview Snapshot — The dashboard should display a broad overview of the process that users can click on to get more detail, also known as “drill-down” capabilities, which are explained below. This overview enables the dashboard to display information of value to multiple user types, whether they are providers, practice administrators, or the credentialing staff. The dashboard should display:

  • Status of providers being credentialed (e.g., new, in process, on hold, completed, or custom credentialing)
  • Counts of providers with insurance
  • Status of the credentialing process by task
  • Credentialing task aging (e.g., 0-30 days, etc.)

Start by looking for these items in your dashboard, and watch your credentialing process go more smoothly.


*Photo is under Creative Commons License.

Outsourcing Provider Credentialing = Gaining Specialization

It makes so much sense that doctors do this all the time. So, why then, isn’t it best practice to provide specialization for the critical tasks in physician offices, such as provider credentialing? It seems as if such a necessary task so vital to protecting a practice doesn’t get the respect or staff resources that it deserves. Instead, credentialing work is simply absorbed by various members of the back-office staff. As a result, the accuracy of credentialing work is often compromised, exposing the organization to financial and patient safety risks.

But rest assured, credentialing specialization does exist, and can be obtained. The answer: Outsourcing. By outsourcing an organization’s credentialing function, physician offices can better focus their staff on revenue-generating tasks, such as billing and collections.

A primary benefit of outsourcing is that it allows provider organizations to access industry-leading expertise on the nuances of physician credentialing, enabling them to get the work done, quicker, better, faster. Experienced credentialing professionals have spent years learning about information resources to verify credentials, which helps them avoid potential pitfalls, and enhance their work through best practices.

Working in harmony: It’s important to note that outsourcing doesn’t necessarily mean that provider organizations have to completely relinquish their control over the function. Rely on the specialization, while keeping the tasks that are easier to manage within the office. This also keeps costs in check. For instance, many organizations choose to retain control over certain aspects, while outsourcing the labor-intensive processes of conducting background and reference checks, or the tedious processes of verifying schools, licensure, employment, malpractice carriers, and more. Experienced outsourcing professionals have the tools, resources and knowledge to perform these tasks faster and more accurately.

With the right outsourcing arrangement and leveraging specialized experts, organizations can remain better focused on their core competencies to improve performance and profitability.

How to Select Credentialing Software

Whether you’ve done it just once, or hundreds of times, you know that physician credentialing is a labor- and time-intensive task. On the flip side, it’s also mandatory if you want to earn reimbursement from payers while also minimizing risks for your practice. Fortunately, there is a silver lining. Software solutions are available to help manage the process. Here are some key features to look for when selecting physician credentialing software.

Cloud-Based. It’s important to look for a cloud-based solution as opposed to traditional software that must be physically purchased on a disc, manually installed and then maintained. Cloud-based solutions can be easily accessed via a browser, are available on a pay-as-you-go subscription basis, and upgrades can be done quickly and nearly effortlessly from any location.

Automated reminders and alerts. Reminders and alerts are critical to notify users when tasks need to be completed. For example, credentialing software can remind users in advance when physicians require re-credentialing. Alerts help notify of important upcoming dates, such as when physician certifications and licenses are about to expire. These reminders and alerts, combined with reports listing upcoming tasks, help facilitate greater efficiency so organizations can always stay on top workloads.

Convenience features. Credentialing software solutions should also provide numerous other conveniences. Once physician demographic and other information is entered, the system should be able to reuse that information to pre-populate forms and other materials. In other instances, some software can also remove the need for data entry by pre-populating the physician data. Look for a system with import tools that allow for the seamless extraction of provider information from various forms, including insurance company forms and the PDF documents from the Council for Affordable Quality Healthcare (CAQH). Then, once imported, this information can be used auto-populate other forms. This eliminates the lengthy and time consuming process of re-entering information.

Document management. Systems should include document management capabilities to store forms, correspondence, credential verification materials, and more. This saves time by properly organizing documents into a logical order that can be easily navigated for quick reference, and rids office staff of the stacks of folders with hard copies.

With the right software solution, credentialing can be a more streamlined and consistent effort throughout any organization. With the right software, you just might welcome the new staff physician who needs to be credentialed.

Credentialing nightmares

The credentialing process, notorious for its red tape and endless paperwork, can be a literal nightmare for private practices. Regardless of size or type of the practice, the stories I have heard from many are all similar: staff spending hours upon hours poring over intricate paperwork, overwhelmed by the threat of an incorrectly submitted and processed application. While there is no way around it, credentialing is an absolute necessity for billing purposes, legal protection, and the safety of patients – we frequently hear from practice managers who say the process is the most tedious and thankless part of their job.

The threat of negligent credentialing looms over physician’s practices for good reason: in one reported case, a practice faced legal action from a patient injured during treatment. The physician hadn’t been properly credentialed for a particular procedure, and when the patient suffered complications following the procedure, he sued the practice for negligence, leading to a major financial blow to the practice. In a busy practice, it’s easy to overlook the fact that a physician’s paperwork might be out of date. The constant follow-up needed to keep a practice in good standing is incredibly time-consuming, but in a worst-case-scenario, a lapse in diligence could mean the closing of the practice.

While many practices want to maintain ownership of and control over the process, I’ve never met anyone who hasn’t been head-over-heels pleased with the dependable, consistent results and value that outsourcing of credentialing has brought to their practice. ClinicSpectrum’s credentialing services provide 24/7 review and verification of a healthcare provider’s professional license(s), current Drug Enforcement Administration and Controlled Drug Substance Certificates, verification of education, post-graduate training, hospital staff privileges and levels of liability insurance. Once we have confirmed that a provider is up-to-date with their preferred health plans, we provide ongoing support to ensure that a physician is always in good standing.

End the nightmare. It’s easy. This added layer of consistent follow-up, including bi-weekly status reports to all of our customers, allows physicians and office staff to focus on the patients rather than the paperwork.

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.