Develop a strong provider enrollment application
Given the high stakes and complexity of provider enrollment, aligning the function with traditional medical staff services work requires a clear strategy, strong approaches, and adept staff. Otherwise, the process may unravel, jeopardizing revenue, care access, and practitioner satisfaction.
Priming applications and workflows is an essential first step in a successful integration. Every good process starts with a strong enrollment application that covers all applicable requirements from commercial and government payers, accreditors, and federal and state regulators. Enrollment information can be captured in a number of ways, but because time is of the essence, you may need to get creative.
To streamline the vetting process, many organizations develop a single data capture tool that can be used for multiple organizational purposes (e.g., enrollment, credentialing, privileging, marketing) and that reduces duplicative communications and requests to practitioners. Typically, the collection tool should cover the following three categories of information, which often contain overlapping data elements:
- Enrollment in commercial health plans
- Enrollment in federal/state health plans
- Credentialing and privileging
Some institutions are required to use a state-mandated application and may therefore send practitioners addenda to capture necessary information that isn’t covered in the mandatory application.
The following sections outline considerations for common data collection tools.
Paper application
The data collection application must be concise and relevant, and it should only require what is needed for enrollment. Unlike online applications, paper applications have few built-in features that encourage practitioners to answer questions completely and consistently, which often creates the need for provider enrollment professionals to scrub the data prior to submission. This time-consuming task is fraught with human error and has the potential to delay enrollment. Given the significant burden they place on applicants and credentialing teams, paper applications should be replaced with automated varieties whenever possible.
Online application
An online application is usually generated through an organization’s software; thus, any data entered goes back into the organization’s database. Such an application shouldn’t just mimic a paper version. Ideally, it will be intuitive, concise, and constructed in a way that encourages compliance with instructions. For example, the application should prevent practitioners from advancing without filling in required fields and should feature “skip logic” that prompts applicants to answer only the questions that are relevant to their professional background and enrollment circumstances.
By controlling how data gets added into the application (e.g., through drop-down menus, radial buttons, etc.), the organization can align the condition of the data with the organization’s security and business rules.
CAQH ProView
CAQH ProView is a central repository that many health plans use for credentialing and accepting providers into their networks. CAQH, which houses information on more than 1.3 million providers, captures the data requested on typical enrollment applications, including materials that must be uploaded (e.g., copy of license, certification of insurance, DEA registration). The provider, who can enter all of his or her demographic and credentialing information into the system, “owns” this data and must grant permission for a healthcare organization, health plan, or CVO to access it. The practitioner must also update/re-attest the data’s currency every 120 days. If the payer finds any outdated information when it accesses the practitioner’s CAQH profile during the enrollment process, it will kick back the application to the submitter, who will face either a delay or denial.
Although CAQH use isn’t federally mandated, many individual states, health plans, and medical groups have established requirements in this regard. In this way, CAQH is quickly becoming the “single source” data repository for enrollment and other credentialing activities. In fact, many MSPs field applicant requests to “use my CAQH profile” when credentialing for acute care privileges and medical staff membership. Although hospitals and health systems don’t typically recognize CAQH as an application option, savvy organizations have begun capitalizing on this growing trend by uploading data from CAQH profiles into their applications to provide practitioners with partially populated documents to review. Applicants would then fill in any blanks regarding data not maintained in CAQH (usually fields regarding competency assessment).
Source: News and Analysis