Data Integrity: The Value of Integrating Quality into Your Organization’s Payer Enrollment Activities


Tuesday, September 26, 2017

Data Integrity:  The Value of Integrating Quality into Your Organization’s Payer Enrollment Activities

Data Integrity: The Value of Integrating Quality into Your Organization’s Payer Enrollment Activities

Sep 26, 2017

Author: Cheryl Cisneros, RN, BSN, CPMSM, CPCS


There is no denying payer enrollment is attracting the attention of our senior leaders as health care is driven to find ways to become more efficient with shrinking reimbursements. This is the call to action for Payer Enrollment Subject Matter Experts. We are seeing an evolving industry as more organizations are integrating payer enrollment into credentialing operations to eliminate redundancy as well as build efficiencies. A practitioner database which has defined credentialing/payer enrollment data standards and processes is the solution to ensure an organization’s database integrity. The database is the method to communicate and support a transparent practitioner onboarding process. Patient’s access to practitioners who provide quality patient care is essential to the healthcare organization. The practitioners are available to patients by searching an organization’s public-facing practitioner directory. Organizations are bringing together their credentialing, payer enrollment and recruitment teams to ensure data elements are defined to meet each collaborating partner’s business needs. Together they will need to create a system data standards document.


Many organizations have developed credentialing verification process standards which have been incorporated into policy and procedures. There is a need to ensure payer enrollment has clearly defined process standards which may need some revision or in some instances developed both in practice and in policies. For some organizations, integrating payer enrollment business rules/standards is new uncharted territory resulting in process improvement projects.


We can all agree that a great deal of painstaking work is required to achieve and sustain the integrity of an organization’s practitioner data.


Dedicated quality monitoring practices are essential to sustain a clean practitioner database. It all starts at the time when the practitioner data is imported in keeping with sound data standards, credentialing verification processes and payer enrollment business rules which are provided to staff in policy and procedures. Some examples of credentialing verification data standards are professional licensure, board certification, DEA, education and training, hospital and peer competency evaluations, etc. Payer enrollment business rules would include office practice location Tax IDs, practitioner NPI, group location NPI(s), billing locations, taxonomies, PTAN, open/closed panel, is the location to be listed in public-facing directory, etc. Payer enrollment database business rules are often very complicated, unique to an organization's tax IDs, contract, as well as each governmental and commercial payer. Rules can vary based on practitioner type (for example - physician, advanced practice practitioner, behavioral health, PT, OT, dietician, etc.). Online practitioner directories are a crucial responsibility of payer enrollment. The Center for Medicare and Medicaid Services (CMS) completed audits of online practitioner directories in 2016 for Medicare Advantage payers and subsequently issued guidance and requirements in a January 2017 Executive Summary. If you have not had an opportunity to read the results, I encourage you to do so. Round two of the three audits is scheduled for 2017 and we anticipate the results the beginning of 2018. States have also implemented practitioner directory requirements.


What are some Quality Monitoring Practices?


  • Organizations have created Quality Credentialing and Payer Enrollment Coordinators job descriptions whose responsibility includes auditing and completing database changes.
  • Creating audit tools for credentialing verification and payer enrollment.
  • Instead of reporting audit results as deficiencies, consider an alternative – opportunity for improvement (OFIs).
  • Develop education sessions at staff meetings or huddles based on audit results.
  • Audit 100% of initial appointment files prior to releasing to internal/external customers.
  • Audit 100% of files sent to payer enrollment/managed care committees to ensure they meet the delegation and payer enrollment data business rules.
  • Complete a percentage of reappointment files prior to releasing to internal/external customers.
  • Policy and procedures developed to meet CMS and/or state requirements for practitioner directory(s).
  • Develop standard database audit reports.
    • Active practitioner – Is next reappointment date entered?Is the Medicare next revalidation date entered?
    • Active practitioner – Is there a primary office and billing designation checked?
    • Expiration reports – Board certification, malpractice insurance

Payer enrollment is challenged by the inherent complexities as defined by contracted commercial payer, state and CMS requirements. Practitioner data standards are essential to ensure the practitioner data which is sent in outbound reports and posted in directories reflects the current practitioner relationship with your organization as an employed or community-based. This is no easy feat and has huge financial implications for your organization. This article is an opportunity for additional conversations to share best practices and solutions. We would love to hear how you and your organization is meeting the challenge!

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