THE FUTURE OF CREDENTIALING & ENROLLMENT

THE FUTURE OF CREDENTIALING & ENROLLMENT

President Donald Trump has promised to modify the Affordable Care Act. Though specific initiatives have not been completely hammered out, new leadership in the White House and Congress is likely to bring about change. Efforts to amend the law are expected to be directed toward lowering costs and expanding consumer choice. New healthcare policies means we may see Trump impact medical credentialing and provider enrollment. As critical components of the revenue cycle, these processes need to be optimized so that providers can keep pace with industry and legislative developments.

CHANGES TO PAYER POLICIES AND NETWORKS

As part of his plan for healthcare reform, Trump has suggested expanding insurance sales across state lines, as long as policies comply with state regulations. This has the potential to expand the number of payers offering insurance in each state. Consequently, practices may have to contend with additional data requirements as providers enroll in increasing numbers of health plans. Practices should be prepared to manage these requirements efficiently.

The new administration may also make changes to Medicare by implementing performance-based standards for physicians. Though specific stipulations haven’t yet been defined, they will likely align with guidelines adopted by the Physician Consortium for Performance Improvement. If MACRA becomes law, Medicare will increasingly move toward value-based care. The Department of Health and Human Services (HHS) has stressed the importance of streamlining processes to comply with additional data requirements. Furthermore, the HHS is expected to delay implementing MACRA to give providers time to prepare for the new mandates. Practices will need integrated, up-to-date information systems to track and verify data to enhance all aspects of the revenue cycle.

Additionally, payers may be granted more flexibility in dictating what services they cover, which could impact plan design and provider networks, ultimately affecting provider enrollment.

OPTIMIZING CREDENTIALING AND ENROLLMENT

With the anticipated emphasis on value-based care, transparency, and consumer choice, practices should implement solutions that ensure accurate, efficient data management. Like other data-driven processes, credentialing and enrollment need to be streamlined to avoid revenue cycle disruptions and promote compliance with updated guidelines. Moreover, the additional demands placed on practices by value-based care may require them to hire additional practitioners across several specialties to manage the continuum of care. Below are a handful of steps practices can take to prevent revenue loss and other problems later on:

•Conduct an assessment of your credentialing and enrollment department. Consider the technology you’re using and consult with staff about how the system could be improved.

•Use real-time metrics to engage your team in the process.

•Utilize technology to connect providers’ gross charges to their in-process applications, focusing primarily on enrollments with payers with the highest revenue associated with their in-process applications. Next, direct activities related to payers with lower dollar amounts tied to in-process applications.

•Use credentialing and enrollment software that minimizes redundant data entry and allows real-time access to multiple data sources that can be shared with payers as needed. Cloud-based solutions enable all departments involved to view information simultaneously to make the process especially efficient.

•Standardize processes and establish performance indicators so you can regularly evaluate progress and readily make improvements.

The continued progression toward value-based care may present challenges for practices struggling to innovate. However, being prepared is essential to optimize revenue cycles during times of transition. Each year, a single provider may enroll with as many as 30-40 payers, each requiring long, detailed applications to be completed. Errors are likely, leading to denials and delays. Automating and streamlining your credentialing and enrollment processes facilitates best practices, enabling you to adapt to ever-evolving healthcare trends.