Checklist for Payor Enrollment Success Overview With Donna

Checklist for Payor Enrollment Success Overview With Donna Goestenkors, CPMSM and Dina Solis February 17 th, 2016

Education Partners 2

Donna Goestenkors, CPMSM + Team Med Global Consulting, LLC 3

Dina Solis + Sonoma Credentialing Services 4

OBJECTIVES Understand the basic principles and processes of a Payor Enrollment program. Learn tips for reducing delays in provider reimbursements. Answer questions about Payor Enrollment. 5

Enrollment Framework Checklist q Definition q Types q 2 -Step Process o Pre = 4 Steps o Post = 4 Steps q Application Attachments q Tip Sheet 6

Payor Enrollment + Enrollment is the process of applying to health insurance plans/networks for inclusion into provider panels to bill and be paid for services rendered. 7

TYPES + Federal & State (Medicare, Medicaid) + Private & Commercial (BCBS, Aetna, UHC) + Worker’s Compensation 8 (Commercial, US DOL)

Two Steps • Pre-Enrollment • Post-Enrollment 9

What is the Process? Pre-Enrollment + Step 1 – Determine Which Plans to Enroll. + Step 2 - Collect Provider Info & Documents. + Step 3 - Obtain, Complete & Submit Application. + Step 4 – Follow up Until Determination is Made. 10

Pre-Enrollment Step 1 – Determine Which Plans to Enroll + Pre-determined based on group/hospital etc. ? + If not, resources (AIS Directory of US Health Plans). + Go to each payor’s website, call Provider Enrollment/Relations for enrollment information. 11

Pre-Enrollment Step 1 - Tips on Questions to Ask: + Special requirements/licensing required? + Typical time frame for processing? + Preferred submission method? If paper, Fed. Ex vs PO Box? + Does payor accept/use CAQH? 12

Pre-Enrollment Step 1 - Tips on Questions to Ask: + Does payor permit backdating? If so, how far back? + Fee schedule? + Forms – EFT, ERA, EDI etc. + If Out of State Provider: + Do they allow OOS Providers? (Primary/X-over? ) + Any special requirements for OOS Providers? 13

Pre-Enrollment Step 2 – Collect Provider Info & Documents + Pre-application, CAQH, NPI registry, repository. + Review/QA for completeness/accuracy. + Check addresses, zip codes and counties on USPS website. + Check names/addresses/expiration dates on licensure and supporting documents. 14

Pre-Enrollment Step 3 - Obtain, Complete & Submit Application Elements + Instructions (great reference for most questions!) + Provider Identifying Information, Education, Training + Provider Licensure, Certifications, Affiliations + Provider References & Work History + Practice Information/Description/Services + Professional Liability Insurance 15

Pre-Enrollment Step 3 - Obtain, Complete & Submit Application Elements (Continued) + Billing Info/Clearinghouse/3 rd Party Administrator + Attestation Questions/Disclosures + Ownership/Controlled Interest Disclosure + Information Release/Acknowledgements + Provider Agreement(s)/ EFT Agreement + Checklist of Attachments 16

Typical Application Attachments Required + All applicable Professional, Medical, Federal, State, & Local Licensure, Certifications, Registrations. + IRS Issued CP 575 & Signed/Dated IRS W 9. + Articles of Incorporation/Partnership Agreement, etc. + Professional Degree, Fellowship, Residency, CEU, DL/Pic. + Professional & General Liability; Workers Comp (if app). + Copy of Voided Check (for EFT agreement). + Copy of Lease Agreement for Practice Location (CA). + Application Fee (if applicable). 17

Pre-Enrollment Step 4 – Follow up Until Determination is Made Communication, Communication! + Follow up with payor (email, phone, fax). + Respond promptly to any requests for more info. + Give updates to provider or supervisor/log into system. + If approved, you may need to ask for an acceptance/welcome letter, or duplicate letter. + If denied, ask why and when to re-apply. 18

What is the Process? Post-Enrollment + Step 1 – Obtain Proof of Enrollment/Denial. + Step 2 - Implement with Billing Department. + Step 3 – Record/Load New Contract in Database. + Step 4 – Maintenance for Continued Enrollment. 19

Post-Enrollment Step 1 – Obtain Proof of Enrollment/Denial. Step 2 – Implement with Billing Department + Assist with any applicable EFT, EDI, ERA paperwork. Step 3 – Record/Load New Contract in Database + Executed copies; welcome letter; ensure provider is loaded into payer network system. Step 4 – Maintenance for Continued Enrollment + Send any changes/updates/lics. to payer; re-attest. 20

Tips for Reducing Reimbursement Delays + Begin the enrollment process immediately upon collecting provider’s information/documentation. + Automate the enrollment process with credentialing software to the greatest extent possible. + Lessens errors & omissions. 21

Tips for Reducing Reimbursement Delays + Minimize the use of paper forms whenever possible. + Expedites process with some payers. + Respond to payor requests as soon as possible. + Communicate proactively with providers and all stakeholders! 22

Tips for Reducing Reimbursement Delays Provider Relations Key Success Tips + Get to know your provider representative by name. + Use your skills as a Leader to impact the process. + Stay actively connected to maintain relationships, facilitate information flow and trouble-shoot. + THANK them, frequently. + Connect with them on Linked. In. 23

Enrollment Framework Checklist q Definition q Types q 2 -Step Process o Pre = 4 Steps o Post = 4 Steps q Application Attachments q Tip Sheet 24

POWER THOUGHT 25

Part 2 Checklist for Payor Enrollment Success – Focused Wednesday, March 16, 2016 Noon – 1: 00 p. m. CT 26 26

And now, a word from our sponsor… For more information email sales@symplr. com 27

Speaker Contact Information Donna Goestenkors, CPMSM + Team Med Global Consulting, LLC + Donna@teammedglobal. com + Telephone: (618) 830 -0057 + Website: www. teammedglobal. com + Like Me: www. facebook. com/teammedglobal + Connect with Me: www. linkedin. com/donnagoestenkors + Follow Me: www. twitter. com/teammedglobal 28

Speaker Contact Information Dina Solis, Owner + Sonoma Credentialing Services + P. O. Box 4661 + Petaluma, CA 94955 -4661 + Dina@sonomacredentialing. com + Telephone: (855) 707 -9995 + Website: www. sonomacredentialing. com + Like Me: www. facebook. com/Sonoma. Credentialing. Services + Connect with Me: www. linkedin. com/in/dinasolis 29

RESOURCES + Field Experience + Team Med Global Consulting + Sonoma Credentialing Services + Interviews + MSPs & Enrollment Specialists 30 30

Credentialing Tool 31

The Medical Services Professional Career Guidebook Features include: + Frequently asked career questions by MSPs + Sample job descriptions, career assessment tools, competency development plans and more + Real-life stories to illustrate career decisions + Purchase today or order your copy: 32 • www. teammedglobal. com • donna@teammedglobal. com • gday@kamama. net

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