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Format: On-Demand Webinar
Presenter: Tammy West, MHA/ED, CPMSM, CPCS
Time: You can access the webinar anytime
Duration: 60 minutes
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The payor enrollment process can take six months or longer for commercial payors. It is a time-consuming process that creates barriers to practitioner onboarding and revenue generation. Payor enrollment can delay the onboarding process for months, especially with commercial payors. These delays create issues with provider satisfaction, patient satisfaction, revenue generation, access to care and, ultimately, patient safety.

Delegated credentialing can simplify the enrollment process by allowing health care organizations to accept responsibility for credentialing their own providers. There are several steps involved in becoming delegated with health plans. Organizations must complete a pre-delegation process, including a file audit and review of their policies and procedures in order to become delegated with a payor. Once the organization is delegated, they are able to control the credentialing and approval process for the payor and greatly reduce the timeline for payor credentialing.

This presentation will review how payor enrollment and delegated credentialing affect revenue cycle. Focus will be given to the benefits of delegated credentialing and steps to successfully complete a pre-delegation audit and implement a delegation agreement with payors.

Learning Objectives

  • Define payor enrollment, delegated credentialing and revenue cycle
  • Explain the difference between payor enrollment and delegated credentialing
  • Discuss payor enrollment and delegated credentialing’s impact on revenue cycle
  • Compare payor enrollment turnaround times
  • Determine the feasibility of delegated credentialing for your organization
  • Understand the steps to become delegated with health plans

Areas Covered in the Session

  • What is Revenue Cycle?
  • The Effect of Onboarding Delays on Revenue Cycle
  • Payor Enrollment
    • Medicare (PECOS)
    • Railroad Medicare
    • Tricare
    • Medicaid
    • CHIP
    • What is Payor Enrollment?
    • Government Payor Enrollment
    • Federal & State Plans
    • Commercial Payor Enrollment and Timelines
  • Common Denial Reasons
    • Uncredentialed Provider
    • Timely Filing
  • What is Delegated Credentialing?
  • Delegated Credentialing Timeline
  • Delegated Credentialing – Impact on Revenue Cycle
  • Delegated Credentialing – Determining the Feasibility
  • Compliance
    • Credentialing Plan
    • NCQA Guidelines CR8
  • NCQA CR8: Element A-Delegation Agreement
  • NCQA CR8: Element B – Pre delegation Evaluation
  • NCQA CR8: Element C – Review of Delegate’s Credentialing Activities
  • Element D – Opportunities for Improvement
  • Staffing Levels
    • Determine Adequate Staffing Levels
    • Specialist To Provider Ratio
  • SBAR Analysis
    • Situation
    • Background
    • Assessment
    • Recommendation
  • Credentialing Turnaround Times
    • What is your current turnaround time?
    • Does it meet payor requirements?
    • Track and trend TAT
  • Software
    • Software Compliance
    • Secure Environment
    • Audit Reporting
    • No Surprises Act
  • Delegated Credentialing – Software Comparison Grid
  • Review Guidelines for Credentials Committee & File Approval
    • MSO
    • CVO
    • Medical Practice
    • What would your approval process look like?
  • CR 2: Credentialing Committee
  • Delegated Credentialing – How?
    • Determine Eligibility Requirements
    • Document Review
    • Credentialing Plan
    • Initiate Pre-Delegation Process
  • Credentialing Software
    • Audits
    • Practice Information
    • System Security and Access
  • Preparation for Pre-Delegation Audit
    • Perform Self-Audit of Potential Files
    • Virtual vs. Onsite Audits
    • Staff Education
  • Next Steps
    • Delegation Agreement
    • Legal Review
    • Fee Schedule Negotiation/ Acceptance
    • Contract Execution
  • Credentialing Process
    • Quality Issues/ Complaints
    • Ongoing Sanctions Monitoring
    • Medicare Opt-Out
    • Credentialing System Control/ Audit Log
  • Approval Process
  • Reappointments
  • Reporting and Rosters

Suggested Attendees

  • Authorized officials
  • Delegated officials
  • Revenue cycle directors
  • Credentialing
  • Enrollment
  • Office Manager
  • Revenue Cycle
  • Operations
  • Billing Team
  • In and Out of Network Providers
  • Medical Billing Companies
  • Providers’ Office Staff
  • Physician
  • Hospitals and Facilities
  • Insurance Companies
  • Healthcare Attorneys
  • Executive and Administrators
  • Front Desk
  • Scheduling
  • Authorizations Staff
  • Medical Assistants
  • Certified nursing assistants
  • Credentialing and Enrollment Specialists
  • Practice Administrators
  • Revenue Cycle Managers
  • Provider Enrollment Managers and Directors
  • CVO Managers and Directors

About the Presenter

Tammy West  is Director Professional Services for The Hardenbergh Group. She brings  25 years of experience in healthcare administration and 16 years in Medical Staff Services. Tammy specializes in CVO operations, provider credentialing, provider enrollment, quality analysis, quality improvement, quality auditing, delegation audits, and policy and procedure creation and implementation. She has extensive experience with CMS, TJC and NCQA requirements for provider credentialing and medical staff services.

Prior to joining The Hardenbergh Group, Tammy was a consultant and independent contractor for hospitals, health systems, CVOs, locum companies and private practices across the United States. She has vast experience as an MSP, including credentialing specialist, provider enrollment specialist, medical staff coordinator, Medical Staff Manager, and CVO Director.

Tammy was a CVO Manager where she was responsible for creating and implementing policies and procedures for a new corporate CVO for a large health system. During her tenure,  the CVO achieved NCQA accreditation and delegated credentialing status with commercial payors. Additionally, Tammy worked as a quality auditor for an NCQA certified managed care company and an Adjunct Instructor teaching medical office systems classes.

Tammy has a BS in Human Services Management and a master’s in healthcare administration with a minor in Education. She is a member of the North Carolina Association Medical Staff Services and the National Association Medical Staff Services.

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