Integrating Provider Enrollment in your MSO 4/7/2019 2:55 PM Integrating Provider Enrollment in your MSO Carrie Bradford, MHA, RHIA, CPMSM, CPCS Senior Director Professional Staff Services and Credentialing Northshore University HealthSystem Evanston, IL © 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries. The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

Historical Perspective Once upon a time 12 years ago this was my reality… Challenges Staff training File Quality Lack of understanding of process by outsiders Database semi implemented Paper files from previously merged hospital, scanning capable but not used.

Historical Perspective Challenges Medical Staff process appended to managed care contracting??? Whoa! Policies and Procedures – how do I do this? Managed care contacts – what they taught me Peers …my office based colleagues Our regulatory friends…what did I need to consider? (TJC, NCQA, URAC, CMS, IDPH??)

Reality of Today Delegation with all major healthplans 1600 providers approximately, depending on contract (important – who is the customer?) Data repository and design to support process Cross Trained Staff Created tools to meet regulatory needs of plans which streamlines audits Let’s talk about clinical privileges… Provider Enrollment with government entities

Strategy Lots of similarities Primary Source Verification, Credentials Committee approval… Leverage you files, data and software functionality Aren’t we the experts??? Focus on the differences to be successful Checklists- why? Site Visits Quality Measures Complaint Process/Adjudication

Provider Enrollment Basics 4/7/2019 2:55 PM Provider Enrollment Basics Traditionally a function of the business office or finance Completion of forms/processes to enroll providers for payment for services rendered Best practice: should always be for providers who are your employees or are contracted for. Watch out for stark! © 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries. The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

Provider Enrollment Basics 4/7/2019 2:55 PM Provider Enrollment Basics Definitions Facility and Organization Dependent Government Plans Medicare/Medicaid Contracted Plans Commercial/Third Party Payors: BCBS, Aetna etc.. Facility Credentialing What is it?... © 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries. The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

Government Plans - Basics Medicare 101 Part A – Part B 855-I & 855-R List of accepted providers – pull the regs! Specialties vs. Taxonomy Paper submission vs. Electronic PECOS (Provider Enrollment Chain and Ownership System

Government Plans Basics Medicare Administrative Contractors (MACS) National Government Services (IL) Process Enrollment Process Claims Maybe different for DME and Home Health Determined/Contracted by CMS Medicare “opt out” lists are on MAC pages for your state

Government Plans Medicare Enrollment Process Paper vs. PECOS Wait…lets not forget about location…location Medicare provider helpline on your MAC website Paper vs. PECOS Leverage your software Use the correct form, if not sure call the hotline TAT with MAC Claims retro back 6 months

Government Plans PECOS The NPPES (National Plan and Provider Enumeration System) NPI login is a providers PECOS Log in Provider must grant you authority to change record on their behalf. (pecos, npi meaningful use) Identity and Access System of CMS designates your level of access. This is granted by your organizations Authorized or Designated Official

Government Plans Medicaid Enrollment State based process IMPACT – IL electronic enrollment IL now ONLY does “Managed Medicaid” – County Care, Illinicare, BCBS, Meridian Other state programs can be intertwined in this enrollment TAT varies, IL still reporting via legacy system Leverage your software where you can

Government Plans Revalidation Requirement of the Affordable Care Act Reduces Fraud/Waste Cleans up the MAC mess (maybe?) Once every 5 years…this is really not true in all cases Consequences for not completing (ordering DME, medications, and of course delayed payment)

Contracted Plans Managed Care Contracting Who – IPA, PHO… What – providers/large groups Why – for reimbursement at a GOOD rate How – thru a contract Where do we fit in?? NCQA, URAC….and delegation

Contracted Plans Managed Care Credentialing CAQH…Council for Affordable Quality Healthcare Data repository “Proview” Plans must give provider a number Data entry along with certificates Initial and Recredential – Reattest every 180 days Duplicative for some

Contracted Plans Managed Care Credentialing Delegation Addendum to your managed care contract – READ IT Yearly audit…even for those who have NCQA CVO cert Checklist Gets your providers in quickly…$$$ Rosters Information Updates No secondary database requirements

Resources Websites: List of MACS Medicare Managed Care CAQH https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/MACJurisdictions.htmlwww. Medicare Managed Care https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/mc86c06.pdf CAQH http://www.caqh.org/solutions/caqh-proview-providers-and-practice-managers

Questions? Thank you! Email: cbradford@northshore.org