I’m here to share with you over the next few minutes several challenges that you may be having, uh, in your claims in getting paid and getting paid as quickly as you should that may be related to your credentialing processes.
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Welcome, everyone, and thank you for joining me for a brief segment on credentialing components to your claims challenges. My name is Brandy Brimhall, and I am with Rapid Credentialing, and I’m here to share with you over the next few minutes several challenges that you may be having, uh, in your claims in getting paid and getting paid as quickly as you should that may be related to your credentialing processes.
It doesn’t matter if you are here joining me from a chiropractic practice, physical therapy, massage therapy, acupuncture, or an integrated facility. The information I’m going to share with you over the next few minutes could potentially help resolve some of your billing and collections challenges, your credentialing problems, and help you get paid faster.
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So let’s go ahead and go to the slides, and I’ll jump in As we get started, again, we’re going to be covering, uh, at a high level the credentialing component to your claims processing challenges. So as we get started, what I’m actually going to share with you is sort of a high-level review of what those claims processing challenges are, and then as we conclude, I’m going to go through a bulleted list for you to really just help you hammer down what might relate to your practice and how to fix that, and really where to look to resolve those issues.
So really just covering a quick, uh, moment of really the foundation or the fundamentals. If you like to look at your business as sort of a brick-and-mortar, the three components that at least in my view make that up have to do with patient visits and patient care, rules and regulations, and so this isn’t just your state rules, but our compliance rules, our payer policy guidelines, and all of those things that help us to make sure that we’re getting paid properly in the best position to keep the money that we have been paid.
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And then, of course, that other component is the revenue cycle system and all of the moving parts of that. We’re not going to be going through all of that today, of course, but the two components that we are going to be foc- focusing on in the topic that we’re discussing has to do both with the rules and regulations side and our revenue cycle system side.
So I’ve spent my career of almost 27 years now problem-solving with the revenue cycle system, and I’m going to share with you as it relates to a piece of the, of the com– the revenue cycle system and credentialing and enrollment that may well relate to you and again solve some of the problems you have.
So I first want to share with you really how enrollment and credentialing works. So first of all, what you want to know right out of the chutes is that if you’re enrolled and credentialed with a third-party payer, that doesn’t mean you’re credentialed and enrolled with all of the plans and products under that network.
That means you may have Medicare Advantage plans, Medicaid plans, other outlier plans under your contracted networks that you’re not in-network with. And so you may see claims coming in processing out-of-network for some payers where you believe that you are in-network with that payer. So again, you could be in-network with Aetna, for example, but out-of-network with some of their plans and products.
Enrollments, of course, must be maintained, and so once you’re co-contracted and enrolled with a third-party payer, that doesn’t mean you’re contracted and enrolled forever. Each of your enrollments are required to be maintained, and that means re-credentialed, attested, verified, and validated at a specific and set time period through your payer portals and with the payers directly.
If those verification or re-credentialing periods are missed, you well could lose access or enrollment status to some of the plans if not an entire contracted network Next, industry and network changes may require re-enrollment or re-credentialing. In other words, the payers as they sit today, in six months from now or a year from now, may have well likely added other plans and other products.
Maybe other payers have moved into your area or made changes. Maybe there’s been mergers with payers or departures of payer relationships and networks that impact how you’re credentialed and what steps you need to take in order to get credentialed or maintain your existing credentialing and enrollment.
So being aware of what’s taking a pl- taking place in the industry and certainly in your region can also impact your claims and collections and of course, your credentialing and enrollment status The next thing I want to share with you is contracting and enrollment is not the same process as your EDI and ERA enrollment.
This is another one of the questions I get across my desk all of the time is, “We’re contracted and we’re enrolled now with whatever third-party payer, so we can automatically bill.” You can bill, but you need to make sure that you’re first set up correctly in your clearing house so that you’re eligible to submit electronic claims and then ideally, of course, receive electronic remittance advice back.
So those are two distinct and separate pro- processes that often impact whether or not your claims are making it to the payer to be processed. Moving forward, I want to share with you how to confirm your enrollment with the plans and products, and so a few ways to confirm enrollment, and what I mean by that is you may be wondering now, “Okay, well, we are credentialed with Blue Cross of our state or Aetna or Cigna or whatever third-party payer, but how do I really know what list of plans and products my provider or our providers are enrolled with?”
There’s a couple of different ways to find that out, and I’m going to share with you now. The first one is you want to make sure that you’re utilizing any relevant payer portals, and so that could be ASH, Availity, Optum, and whatever of other portals may relate to the payers that you’re submitting. The other way to find out is to call provider credentialing to your third-party payers.
Understanding being one that does this on a regular basis, you may go through hold times, but once you’re able to get that information, it’s immensely helpful for your office at the front desk level, whoever is verifying benefits, certainly whoever is communicating payer expectations and coverage benefits and limitations to your patients, and then, of course, in billing as well.
It also helps you to know if there are other plans you need to be enrolled in or not. So you can contact your payers, again, through portals or by phone to confirm what’s called a plan list or a plan roster. Keep in mind, too, that these can change over time. If you were contracted recently or even many years ago, there’s an excellent chance some of the plans that are available now are, are either weren’t available at the time you enrolled or perhaps have been pulled from your existing enrollment because those plans are no longer in existence, and so networks do make changes that impact our clinics and our billing.
Everything to do with the revenue cycle system is imperfect. It’s always gonna be imperfect, and really, it’s an industry of constant change, and so it’s something we need to be aware of and know what to look for as we’re navigating our billing and revenue cycle system processes. So with that being said, you may find that you need to add plans and products to existing contracts.
At Rapid Credentialing, we call that adding lines of business, and we do a lot of enrollments to add different types of outlier plans or different, uh, categories of plans and products to existing provider enrollments, along with new enrollments as well, of course The proactive approach to credentialing and enrollment is always going to be your best approach.
Uh, payers will not generally grant retroactive effective dates, and so what you don’t want to do is find out months later that you’ve been out of network, didn’t know you were out of network, and had an opportunity sometime in the past to, uh, remedy that if that was what you really needed. So when you have questions, if you’re seeing claims not processing through as you would expect, make sure that you’re doing your due diligence to be proactive in peeling back those layers to determine why the claims are processing the way they are, and then obviously what next steps you might need to take in order to add those lines of business or those contracts to your provider or your business enrollments The next thing I want to share with you before we conclude is that EDI component.
So like I mentioned, this is a total distinct and separate process outside of the credentialing and enrollment and contracting process with your third-party payers. EDI stands for Electronic Data Interchange, and this is the communications pathway that you use through your clearinghouse in order to get claims to your third-party payers for processing.
If the EDI isn’t set up correctly, you’re going to find that your claims either aren’t making it to the third-party payer or perhaps are being misrouted to a different processing department than what you would expect, ultimately resulting in denials, claims being dumped, and you receiving nothing at all in return to know that action items need to be taken.
So make sure that you look at your clearinghouse, review your rejections and the reason codes and reason descriptions for those rejections to address those problems promptly. If you’re an out-of-network provider, it is still likely that you are required EDI setup, and so you may be thinking, “Well, I’m not contracted.
Does this matter to me?” It absolutely does, keeping in mind that some of our third-party payers don’t require EDI enrollment at this time, others do. So it’s definitely one of those areas you’re going to want to keep your fingers on the pulse of because there’s a lot of lost time and money in submitting claims and then forgetting about them and assuming they’re just gonna get to where they’re supposed to be, processed, and pay us back accordingly.
We all know it doesn’t always work like, like that, so you want to definitely make sure to keep your eyes on your EDI enrollments and, of course, all of the other related aspects of your clearinghouse. As we conclude, I’m joi– just going to leave you with a few of the common claims issues and some troubleshooting solutions that may resolve some of the claims processing and reimbursement challenges you’re having right now that could perha- perhaps be related to credentialing.
The first one is, we believe we’re in the network, but some of our claims are processing out of the network. Your troubleshooting for that is really going to be to confirm your payer or plan list, that plan roster that I mentioned, to confirm which plans you are really in the network with and which you’re out of the network with.
Again, you can always add those lines of business as it’s applicable Next, claims were previously processed in the network for one or more patients are now suddenly processing out of network. This could be because a missed attestation, cred-recredentialing or credentialing steps were needed to be taken that were certainly missed by the clinic or by a provider.
When that happens, you could certainly find that your claims, some of them for individual patients, aren’t processing the way that you would expect. You’d, of course, need to go back through the layers, make sure you’ve attested on your CAQH, your Availity, your Optum, whatever portals are related, and that you haven’t missed a specific recredentialing period that has ultimately caused termination to an entire network or some of the plans under that network Next, another example is provider is in-network with a local Blue Cross Blue Shield, uh, but an out-of-state plan is processing out-of-network.
So we believe the provider should be in-network because he’s in-network or she’s in-network with our state, but we have a patient from another state with another state Blue Cross, and those claims are processing out-of-network. This is another common one that comes across my desk, and really the way that it works with Blue Cross is there are many plans for in-network providers that cover all of the states if the provider’s in the network in their local region.
There are also state-specific or region-specific plans that are only eligible f- for in-network status with providers for providers in that specific region. So here again, if you’re seeing an out-of-state patient, it’s very possible their plan is not part of your provider’s network in another state. So you want to check that plan roster, make sure you’re verifying the appropriate set of benefits for that.
Next, we have a new provider that’s who, whose claims are rejecting at the clearing house or processing out-of-network. Couple of things to know and to look at, at on that, make sure that your provider is set up in the clearing house for proper claims submission. And then also, of course, make sure that your provider is properly credentialed, enrolled, and assigned to your business or your business group so that they are eligible to submit claims and your business is eligible for reimbursement for that new provider.
And finally, we have claims are being submitted and received, but they’re continually not, or they are appearing to not be processed, and there’s no remittance data that we’re receiving. This is typically through, uh, EDI, through your clearing house, and what you might find is that your claim perhaps could be being misrouted.
Payers will not often reroute claims to a separate processing department, even if it’s in w- within the same company. So you want to make sure that you’re verifying and setting up claims routing properly, because you won’t often receive a letter or a denial telling you that your claims are being rou- routed improperly.
Rather, you’ll often receive nothing at all and just assume that your claim is b- being received at the payer and never processing. So it could be an EDI setup issue, and that’s where you’d want to look and confirm, because keep in mind too, with every single payer we have, we’re on the clock just as soon as that patient, uh, is seen as far as timely filing goes with our third-party payer.
So we don’t want to wait too long and find that we’ve missed the opportunity to get paid at all And then next, the claims are rejecting at the clearing house, citing the provider is not eligible as a submitter. This is almost always related to the provider not being set up at all or not set up properly in your clearing house.
Those steps need to be taken. Once that’s confirmed, certainly you’d want to verify credentialing and enrollment contracts just to make sure that those are intact. Now, I know this has been a very high level and doesn’t cover all of the possibilities of how your credentialing could be related to some of your claims challenges, but I do think we’ve covered several of them.
If you have any questions at all, please feel free to reach out to myself and my team. You can see our contact information right there on the screen. Thank you so much for joining me. I hope this has been helpful, and I look forward to seeing you next time.