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TRANSCRIPT
Introduction to Payor Enrollment
Session Code: WE10
Time: 10:30 a.m. – 12:00 p.m.
Total CE Credits: 1.5
Presenter: Donna Goestenkors, CPMSM and Dina Solis
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Introduction to Payor Enrollment
October 7, 2015
10:30am-12:00pm
Donna Goestenkors, CPMSM
and Dina Solis
Answers
to your
Enrollment
Questions
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Session Objectives
+ Payor Enrollment as a career path for MSPs!
+ Understand the basic principles of Enrollment.
+ Top 10 Enrollment mistakes.
+ Enrollment success tips.
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PREPARE YOURSELF
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Questions From The MSP Field
+ “Is this my future?”
+ “What if I’m unhappy in
my job?”
+ “What should I do if I’m
seeking a new challenge?”
+ “What’s involved?”
+ “Do I have the skills?”
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MSP Career Facts
Transferrable Skills:
+ Detail oriented
+ Understand licensure requirements
+ Identify red flags
+ Doctor FBI
+ Customer Service
+ Regulations interpretation
+ Deadlines
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Is Payor Enrollment for Me?
Enrollment is an Industry Career Path!
Current Position Titles:
Payor Enrollment Specialist
Payor Enrollment Manager
Director, Payer Enrollment
Vice President, Payer Services
Chief Enrollment Officer
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MSP Value
Enrollment Management
+ Federal requirements
+ Health plan requirements
+ Resources
+ Technology
+ Stakeholder satisfaction
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Getting Started
+ Enrollment is a part of the Medical Staff Services
Industry.
+ Embrace the change!
+ Reach out to a mentor.
+ Have a career plan!!
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What Is It Called? Let’s Brand It!
+ Payor
+ Payer
+ Provider
+ Enrollment
+ Contracting
+ Credentialing
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Differences Between
Credentialing
+ Process by which each insurance company verifies
credentials
Contracting
+ Process of making a provider a participant in the
network
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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.
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Types of Enrollment
+ Federal & State
• Medicare/Medicaid
• Tricare
+ Private/Commercial
• Blue Cross/Blue Shield, Aetna, United Healthcare, etc.
+ Workers’ Compensation
• US and State Departments of Labor
• Various Workers’ Comp MPNs, Plans and PPO Networks
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Who To Enroll
Individual Provider vs. Group Provider Enrollment
+ Depends on who the billing will go through (Individual NPI
or Group/Org Tax ID).
+ If enrolling Group, individual needs to also be enrolled
and benefits are normally assigned to the Group.
+ Identify your organization’s internal enrollment processes
(if any!) before starting.
+ Identify desired health plans to enroll in.
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Two Steps
+ Pre-Enrollment
+ Post-Enrollment
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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.
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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 payor’s website, call Provider Enrollment for
enrollment timeframe, any special requirements or
forms, and preferred submission method/address.
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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.
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Pre-Enrollment
Step 3 - Obtain, Complete & Submit Application
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
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Pre-Enrollment
Step 3 - Obtain, Complete & Submit Application
Application Elements (Continued)
+ Billing Info/Clearinghouse/3rd Party Administrator
+ Attestation Questions/Disclosures
+ Ownership/Controlled Interest Disclosure
+ Information Release/Acknowledgements
+ Provider Agreement(s)/ EFT Agreement
+ Checklist of Attachments
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Typical Application Attachments Required
+ All applicable Professional, Medical, Federal, State, &
Local Licensure, Certifications, Registrations.
+ IRS Issued CP575 & Signed/Dated IRS W9.
+ 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).
+ Cover Letter (for paper applications).
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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.
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Highlights…
+ Pre-Enrollment = 4 Steps
+ Contact Provider Enrollment or Provider Relations
+ Refer to each payor’s website for guidance
+ Process
+ Forms
+ Requirements
+ Processing Timeframe
+ Submission Method
+ Key Contacts
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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 payor; re-attest.
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Highlights…
Post-Enrollment = 4 Steps
+ Obtain proof of enrollment/denial
+ Implement with billing department
+ Record/load new contract in database
+ Maintain for continued enrollment
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Reality
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TOP 10 LIST!
Learn the Top 10 Enrollment Mistakes
and How to Avoid Them.
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NUMBER
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Enrollment Mistake #10
Not Submitting the Correct Application(s) for the Provider Type
+ Applications similarly Named/numbered/lettered
• CMS “855” Forms
• State Medicaids (“DHCS___”; “MAD___”;
“KMAP___”)
+ Forms to use depend on the billing entity
• Individual NPI vs. Group NPI (CMS 855I, CMS 855B)
• Reassignment of Benefits (CMS 855R)
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NUMBER
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Enrollment Mistake #9
Not Submitting the Current Versions of Paper Applications
+ If using paper application, be sure to download/use
the most current version.
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NUMBER
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Enrollment Mistake #8
Not Submitting a “Complete” Application
+ Leaving some areas completely blank
+ Not indicating N/A
+ Not including all of the required documents
• Application fee (applicable to the provider type)
• Provider Agreement
• EFT Agreement
• Disclosure of Ownership/Controlled Interest
• Provider Affidavit/Attestation
• Notary
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NUMBER
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Enrollment Mistake #7
Submitting an Application that Contains
+ Errors
+ Omissions
+ Typos
+ Illegible handwriting
+ Copies that are too light/dark; cut off
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NUMBER
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Enrollment Mistake #6
Not Submitting the Required Supporting Documentation/Attachments
+ Licensing/Registrations/NPI/Signed IRS W9
+ Original Signature Pages
+ Additional Provider Agreements
+ Cover letter including ATN (Application Tracking #)
or DCN (Document Control #) on each page of
attachment, if required by payor
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NUMBER
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Enrollment Mistake #5
Submitting Supporting Documents that
+ Are expired
+ Have inaccurate street address
+ Have typo(s) in name of business
+ Have typo(s) in name of license holder
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NUMBER
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Enrollment Mistake #4
Not Ensuring that the Provider/Entity Legal Name Stated on the Application Exactly Matches
+ IRS Legal Entity Name
+ Name on IRS W-9
+ NPPES Registry
+ Licenses/Registrations
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NUMBER
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Enrollment Mistake #3
Failing to Respond Timely to Requests from the Payor for:
+ Additional information
+ Additional documentation
+ Correction of any errors/omissions
Side Tips on:
+ Contact Person
+ Mailing Address
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NUMBER
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Enrollment Mistake #2
Not Signing/Dating the Paper Application
+ Submit wet ink signature when required
+ Be aware of when stamped/copied/faxed
signatures are acceptable
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NUMBER
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Enrollment Mistake #1
Underestimating How Long the Enrollment Process Actually Takes
+ Enrollment Times Vary Greatly by Payor
+ Status Updates/Communicate
• From payor
• To provider
• To supervisor
• Enter into system
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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 LinkedIn.
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Success Points+ Begin the enrollment process immediately upon
collecting information.
+ Automate the enrollment process to the greatest
extent possible: IntelliSoft, symplr (formerly
Medkinetics), CAQH, database software, Morrisey,
HealthLine Systems, Cactus, etc.
+ Minimize the use of paper forms whenever possible.
+ Respond to payor requests as soon as possible!
+ Communicate proactively with providers!
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TOP 10 SUMMARY
1. Use the CORRECT forms for the provider type.2. Use only CURRENT versions of paper applications.3. Submit a COMPLETE, ACCURATE, fully LEGIBLE application.4. Include ALL of the required application attachments.5. Submit a COVER LETTER with each application/supporting
document package. Include applicable ATN, DCN, cover page.
6. Ensure supporting documents are not EXPIRED and have CORRECT name and street address of the licensee.
7. Ensure the legal name on application MATCHES EXACTLY to the IRS document, IRS W-9, NPPES, and licensee names.
8. Respond PROMPTLY to payor requests for additional info/documents. Ensure appropriate Contact Person/Address.
9. Ensure the application and agreements are PROPERLY signed.10. Effectively COMMUNICATE each payor’s processing times and
provide REGULAR UPDATES to stakeholders.
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Utilize Your Resources
Applications, applications and more applications!
Credentialing software can help automate the application process by auto-
populating, tracking, and even submitting applications
+ IntelliSoft, Sy. Med, Morrissey, Cactus, symplr, etc.
+ Some plans have auto-fillable forms you can download from their website
+ Credentialing software can help automate the application process by auto-
populating, tracking, and even submitting applications
+ For paper applications, urge your organization to obtain the full version Adobe
Acrobat Pro. No handwriting!
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Even More Resources & Tips
+ Take the time to accurately enter provider data on applications and in CAQH
and software.
+ Electronically Save, Re-Name, and Upload provider’s credentialing documents
separately ahead of time. No bundled docs!
+ Audit your work. Twice!
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Primary Resource
AIS (Atlantic Information Services Directory of Health Plans 2015)+ Comprehensive directory of all US health plans with member enrollment,
plan type, demographic and contact information.
+ Print, CD, and USB Flash Drive database formats.
+ Website: www.aishealth.com for purchase information.
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Hands On Training
National Provider Enrollment Workshop
+ Dec 7-9, 2015
+ Dallas, TX
+ Decision Health
+ www.decisionhealth.com
+ Early Bird Registration
+ Ends Oct 15th ($200 off)
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POWER THOUGHT
“Your resources are always far greater than you imagine them to be. Never ask, ‘Can I do this?’
Ask instead, ‘How can I do this?”
~Dan Zadra - Author
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Speaker Contact Information
Donna Goestenkors, CPMSM
+ Team Med Global Consulting, LLC
+ 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
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Speaker Contact Information
Dina Solis, Owner
+ Sonoma Credentialing Services
+ P.O. Box 4661
+ Petaluma, CA 94955-4661
+ Telephone: (855) 707-9995
+ Website: www.sonomacredentialingservices.com
+ Like Me: www.facebook.com/SonomaCredentialingServices
+ Connect with Me: www.linkedin.com/in/dinasolis
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