Why credentialing enrollment is important...
Every medical service professional must provide their credentials to the organization for which they are providing the service before they are eligible for full reimbursement and/or granted the privilege of serving in the organization's network or at its facility. The process of giving this provider information to the organization is called credentialing enrollment. The organization receiving the credentials may be a hospital, insurance company, clinic, HMO, MCO, or any of a myriad of other healthcare related entities.
The typical family practice clinic with five physicians can easily be required to submit credentials for these five providers to as many as 40 different entities. Specialty practices often submit credentials to an even greater number of entities. Now, scale those numbers to even greater levels for larger organizations, billing companies or provider organizations like IPAs that sometimes provide these services for multiple practices.
The problem with the Credentialing process in the past has been threefold:
- The intensive amount of labor involved in obtaining, gathering, verifying and maintaining the information for each credentialing application,
- The sheer effort of transcribing all that information to each of the numerous different applications, and
- The critical need for proactivity, to be alerted to what's expiring and when.
"Where does the doctor keep his curriculum vitae?" "Is it current?" "What is the status of his CMEs?" These are questions that cause enormous stress on the credentialing staff. A large portion of the credentialing staff time is spent gathering and verifying this information.
Another time-waster is the process of manually transferring all the required information from the various locations of the required information to the paper application the CVO requires. This can include copies of the medical license (on the doctor's office wall), the CMEs (the doctor's education file), and personal information (from the office personnel files). Once located, they must all be copied, then verified that they are correct.
Now consider that each application is typically nine pages long. Multiply that by the five providers in the clinic and the 40 organizations that each have their own, different application. The amount of time and effort it takes the credentialing staff to prepare these applications can become daunting.
Add on top of that the NCQA and similar requirements that the credentialing process must be monitored and tracked.
To help providers of healthcare services better manage the credentialing process, Wybtrak, Inc. has developed the Credentialing Software Solution. This system transforms this complex, burdensome problem into a timely, manageable task. The software is truly a unique business management tool.
Information entered into the Credentialing Software Solution can be reviewed and updated on-screen, or printed to hardcopy and verified by the credentialing specialist and the provider. To meet NCQA requirements, the provider can initial and date any changes or updates to their information so the appropriate data fields may be corrected/updated. Documents such as educational diplomas, medical licenses, DEA licenses, pharmacy licenses, board certificates and CME certificates, can be scanned and placed right into the physician's credentialing record where it will be a permanent part of the record. It can then be printed with the application form with the click of a single button.
To prepare a credentialing application form is a simple three-step process:
- Select the desired credentialing form
- Select a provider’s name
It’s that simple! Any form for any provider can be retrieved at any time.
The password protected database contains:
- Insurer Specific Information
- Board Certification
- CME Credits
- Liability Insurance Coverage
- Business Information
- Office Information
- Office Standards
- Patient Coverage
- Education & Training
- Medical School
- Post-Grad Training
- Personal Information
- Work History
- Hospital Privileges
To become a certified or accredited medical service provider, evolving NCQA guidelines have mandated that the provider and managed care plan abide to timelines for each of the credentialing entities. This ensures that all documents are current and identifies any item that needs to be sent within the necessary timeframe, which is specific to the entity credentialing the practitioner. Inadequate tracking and monitoring methods such as spreadsheets and paper files that require human memory to be maintained apply unwanted pressure on the credentialing staff and the provider.
The credentialing management module facilitates the ease of tracking and monitoring all credentialing events and expiration dates. At a glance, one can see if the credentialing process is progressing at a pace to satisfy NCQA’s required timelines and if not, where the delay has occurred. Each event is date and time stamped and are as follows: letter of intent, application received, provider data authentication sent, provider data authentication returned, form printed, form sent to provider, provider signed form, received form from provider, attestation signed, form sent to MCO, credentials pended, credentials approved, or credentials denied. Other important date and time stamped information can be entered in the free form notes section, such as phone conversations with credentialing agencies.
The management module includes Status Reports, CME Reports and Expiration Flag Reports (Individual, All or Expiring Only). The user can search for expiring contracts by individual providers, by groups, by physician networks, by managed care plans and by any state in which the provider is credentialed. The number of days until credentials expiration can be preset by the user before the search is executed, i.e. if you want to search for expiring contracts within the next month, you simply enter the number 30 in the field provided and only those contracts expiring within the next 30 days will be found.
In addition, the following expiration dates can be readily tracked and monitored: state medical practice licenses, pharmacy licenses, DEA licenses, board certifications, board eligibilities, board recertifications, workers comp five-hour course, workers comp exempt status, professional liability insurance, general liability insurance, Medicare and Medicaid licenses.
Wybtrak's Credentialing Software Solution is a critical asset to medical service providers, credentialing verification organizations, management service organizations, managed care plans and practitioner networks.