Months of recruiting calls and resumes. Weeks of tiring interviews by busy clinicians and managers, stressful selection and contracting followed by anxious weeks of orientation and onboarding. The investment required for engaging new providers is enormous. All too often this investment ends disappointment when the new provider is unable to bill for the services for which they have been hired.
All healthcare providers have learned that credentialing is a critical component of healthcare business and part of the life blood of getting paid. If all know that to be true, then why is it so difficult to accomplish and sustain?
One recent client project shed some light into this conundrum. A multi-hospital health system with a large community physician group was experiencing a high volume of claims that would not pass through their billing clearinghouse. Staff researching the problem received vague responses from the payors that caused confusion about how to resolve those claims and prevent more from failing. Meanwhile, upwards of $245,000 in monthly denials were accruing. We were asked to help solve the conundrum and get the claims and cash flowing again.
First, Review and Analyze the Data to Diagnose the Problem
A project like this must begin with data. Through the data, we found that while several issues were contributing, 85% of the problem was caused by providers being past due for credentialing. Diving more deeply, we identified that 160 location applications, affiliating 600 of the group’s physicians, were needed immediately to stem the growing log jam of denials.
Unfortunately, local staff had little knowledge of how long the 160 applications would take to complete, submit and receive approval. They also lacked viable technology or tools to organize, track and report on the status of many elements of the 160 applications.
Enable and Organize the Team
Armed with this knowledge, our team quickly coupled automation with a four-step action plan to mitigate the problem:
1. Clarify and simplify the process: We collected the specific data elements needed for the application and verified the submission and affiliation process to ensure the applications were accurate before sending.
2. Automate wherever feasible: The team needed a tool to track key phases of progression through the cycle of Enrollment, Submission, Affiliation and Approval. The tool needed to:
a. Track status by location and physician,
b. Allow multiple team members simultaneous access to update,
c. Assign accountability to specific parties,
d. Allow for detailed notes and status designations, and
e. Generate reports and a dashboard that could be used to communicate our progress.
3. Deploy resources: Armed with knowledge of specific tasks to complete and a tool through which to complete them, a multi-disciplinary team of leadership, hospital staff and consultants were able to complete all 160 location applications within a 3-month timeframe.
4. Monitor & Communicate results: Our proprietary dashboard tool allowed the team to monitor and communicate to all levels of management from senior leadership, to practice managers to individual physicians. The tool also gave our team the opportunity to approach the affected payors with a complete detailed list of providers with similar issues. This gave the payors’ reps the chance to give us global guidance on how to fix each of our gaps versus having to submit individual requests. This capability shortened our final resolution process by weeks!
Results and Lessons Learned
Beyond the improved collections of nearly $250k per month, the physicians were relieved of a great stress. Senior leadership was deeply grateful for the recovered cash flow and reassured to be able to monitor the credentialing team’s progress going forward. They now had a dashboard tool to track credentialing progress and due dates going forward, enabling them to see any backlogs before they became significant. In addition, using the dashboard, they are able to predict the length of time needed to complete various types of credentialing, which has aided them in planning for necessary lead times for new services, adding physicians and opening new health centers.
The Magic Sauce
While this project was significantly aided by data analytics and implementation of custom dashboard, the magic of the success of this was not in the tool or approach used. The magic came for senior management’s commitment to fix the problem and once fixed, to maintain responsibility to hold the right people accountable. Our job was to sift through the data and organize it in a way that allowed leadership to understand what was broken, what it would take to fix it, who needed to participate and be accountable, and feedback to determine if the fix was accomplishing the outcomes needed. At i3 Healthcare Consulting, our job is to simplify problem solving and give our clients the tools and resources to fix them.