Sftware A New Apprach The upcming reimbursement shift frm fee fr service t fee fr quality has generated an increased fcus n ppulatin health management. In rder t ensure a sufficient clinical delivery base, healthcare rganizatins have begun t cnslidate clinical prviders at an unprecedented rate. Current credentialing sftware prducts are nt equipped t handle the cmplexities f a highly distributed, multi- prvider, quality driven reimbursement mdel. Credentialing sftware must ffer an pen and revenue centric slutin which empwers healthcare rganizatins t meet the peratinal and financial demands that ppulatin health management requires.
Backgrund Tday s healthcare industry is underging unprecedented change. As a result f the Affrdable Care Act (ACA), CMS and cmmercial payers are mving frm a fee fr service reimbursement mdel t a fee fr quality mdel. One f the primary ways that healthcare rganizatins are lking t capitalize n the fee fr quality reimbursement mdel is t mve tward ppulatin health management. Defined rughly as prviding the cmplete cntinuum f clinical care fr a gegraphic ppulatin frm pre- admissin wellness, t service line clinical delivery, t pst- discharge wellness fllw up, the gal f ppulatin health management is simple: keep peple frm having t g t the hspital and in the event that they have t g t the hspital, prvide the right care acrss all specialties s that nce they are discharged, they d nt have t g back t the hspital. In respnse fr successfully accmplishing the abve, any cst savings that are attained will be shared between CMS/cmmercial payers, and the healthcare rganizatins/prviders. The mve t ppulatin health management has frced healthcare rganizatins t ensure that they have the apprpriate number f primary care and specialty prviders in rder t successfully treat their gegraphically based patient ppulatins. This in turn has had a dramatic effect n the revenue f healthcare rganizatins and has gained the attentin f every healthcare leader in the cuntry. Whereas healthcare leaders were previusly cncerned primarily with cre revenue cycle cncepts including scheduling, insurance verificatin, authrizatin, charge capture, medical cding, and accunts receivables fllw up, healthcare leader attentin is nw fcused n the direct linkage f prvider n- barding, linking thse prviders t the apprpriate payer(s), and identifying the financial impact f thse linkages t their ability t cllect n their ppulatin health delivery initiatives. Frm a credentialing and prvider enrllment perspective, healthcare leaders are realizing that their current credentialing sftware capabilities are limited at best and that new alternatives are critical t successfully maximize their shift tward ppulatin health management. Ppulatin Health Management and Prvider Credentialing Sftware In rder t understand the impact f ppulatin health management n the credentialing sftware industry, we shuld first lk at hw healthcare rganizatins are a) hiring mre and mre prviders t meet a critical mass f needing t emply primary and specialty prviders, b) mving nn- critical, ambulatry services ut f the hspital and int ff- site lcatins and c) hw healthcare leaders are mandating that all f their healthcare prviders prvide service acrss all clinical delivery lcatins. In rder t ensure that healthcare rganizatins can meet the demands f ppulatin health management, as well as reap the benefits f attained cst savings and imprved patient utcmes, healthcare leaders and rganizatins have been acquiring physicians and allied health prviders at an unprecedented rate. Accrding t a January 9 th, 2012 article in Fierce Healthcare, Hspitals'ʹ physician emplyment jumped 32 percent frm 2000 t rughly 212,000 physicians in 2010, accrding t the 2012 editin f AHA Hspital Statistics. That means hspitals emply almst 20 percent f all physicians, ntes a Hspitals & Health News Daily article. Fierce Healthcare cntinues, What'ʹs mre, the amunt f hspitals emplying hspitalists rse 2
frm 29.6 percent in 2003 t 59.8 percent in 2010. 1 The impact f this hiring binge has been a negative impact n healthcare rganizatin s revenue due, in part, t inadequate credentialing sftware and services skill sets. Additinally, due t increasing csts as well as a premium n hspital square ftage, increasing numbers f healthcare rganizatins are mving nn- critical, ambulatry services ut f the hspital setting and int ff- site lcatins. The cncept is simple, take nn- critical, lw revenue generating services ut f the hspital and replace them with critical, high revenue generating services. N lnger are hspitals being viewed as an all in ne clinical service prvider. Rather, they are being viewed as service delivery experts fr nly the mst cmplex clinical services. As a crllary, nn- critical, lw revenue generating services are being mved ff- site and directly int the cmmunity. The impact f this shift is a) t ensure that prviders are managing the health f their ppulatin within the cmmunity itself and b) the ambulatry centers will serve as a feeder fr any in- patient, hspital based services. As a result f this shift, healthcare leaders are mandating that their emplyed prviders prvide services acrss all ff- site lcatins. Fr example, prviders that previusly prvided services at nly ne r tw lcatins are nw prviding services at multiple lcatins (bth within their emplyed healthcare rganizatin as well as with cmpeting healthcare rganizatins). With this ppulatin based and multi- lcatin delivery shift, healthcare leaders are realizing that they need t credential and enrll their prviders acrss all lcatins. Hwever, in ding s, they are realizing that the credentialing and enrllment prcess becmes incredibly mre cmplicated. When cupled with the negative revenue impact that nt crrectly crss credentialing their prviders entails, healthcare leaders are realizing that existing credentialing sftware tls are nt equipped t meet these newly emerged, multi- faceted demands. Credentialing Sftware A Brief Histry In rder t best understand hw the credentialing sftware industry can meet ppulatin health based demands, we shuld first understand the histrical evlutin f the credentialing sftware industry. Prir t the advent f credentialing sftware, mst gvernment and managed care prvider enrllment applicatins were filled ut manually (e.g., paper and pen). Prviders wuld cmplete 20-25 applicatins with an average length f 30-40 pages. Typically, it wuld take 2-3 hurs t cmplete ne applicatin and all data was paper based. In the late 1990s, sftware cmpanies develped sftware that reduced the data entry time needed t cmplete a credentialing applicatin by allwing a physician t enter demgraphic data int a client server database and aut- ppulate applicatins frm the same database. As a result, physicians nly had t enter data ne time, but in ding s, culd ppulate all 25 applicatins at the same time. Whereas it may have previusly taken a physician 40 hurs t ppulate and submit all f his/her applicatin(s), it nw nly tk 4 hurs. While tremendusly innvative at the time, mst credentialing sftware tls have nt evlved past this pint. In particular, credentialing sftware tls have nt adapted t the demands f a ppulatin health based management in the fllwing ways: 1 http://www.fiercehealthcare.cm/stry/hspitals- emplying- 32- mre- physicians/2012-01- 09 3
They d nt ffer a clud based, multi- lcatin, 24/7 web accessibility Because they are client server based, they d nt have the prgramming flexibility t adapt t the changing healthcare envirnment in a rapid and flexible manner. Enhancements, if any, are rlled ut spradically, and nly fr thse users wh are willing t pay an enhanced fee. They d nt ffer easy t understand crss- lcatin peratinal and financial perfrmance metrics. It is incredibly difficult t understand an rganizatin s perfrmance frm an Institutin, Facility/Lcatin, Department/Office, Prvider, r Payer perspective. They d nt ffer flexible, system generated wrk list and fllw up capabilities They d nt ffer rbust analytics that allw the user t cnduct data analysis s as t identify peratinal, financial, r payer bttlenecks They d nt ffer quality assurance mechanisms They d nt ffer prductivity standard tracking mechanisms They d nt incrprate revenue and physician credentialing life cycle metrics int ne unified tl They d nt ffer the ability t link grss charges t their in- prcess applicatins They d nt ffer Key Perfrmance Indicatrs (KPIs) They d nt ffer revenue cycle metrics such as: Days In Enrllment (DIE) calculatins They d nt ffer payer perfrmance metrics t keep payers accuntable They d nt ffer a way t link prvider credentialing data with prvider clinical utcme data Based n this assessment, it is evident that the existing credentialing sftware tls have nt adapted t the demands f a ppulatin management reimbursement and a new apprach t credentialing sftware must be created. Withut tls t meet these grwing demands, healthcare rganizatins will experience an increase in credentialing related denials, frustrated prviders, and a lss f critical revenue. Credentialing Sftware A New Apprach In rder t meet the demands f a ppulatin health management, health leaders must ask their credentialing sftware vendrs fr new ways t help them meet their cmbined crss- lcatin, revenue centric needs. Health leaders wuld be well psitined if they demanded the fllwing credentialing sftware functinality: Clud based, Multi- Lcatin, 24/7 Web Accessibility. Credentialing and revenue data shuld be available t anyne wh has access t the internet and has a user name and passwrd. All data shuld be stred in the clud and healthcare managers and prviders shuld be able t access their credentialing data and identify where they are in the enrllment prcess s as t ensure that they are nt lsing revenue due t delayed credentialing timeframes. Anther benefit f being in the clud wuld be a dramatic reductin in upfrnt capital expenditures. N lnger wuld a healthcare rganizatin need hardware, servers, sftware, r staff t subsidize their credentialing systems. Rather, all f their sftware 4
wuld be hsted by a HIPAA and HITECH apprved vendr and the vendr wuld bear all hsting and data encryptin csts. Institutin, Facility/Lcatin, Department/Office, Prvider, r Payer Operatinal and Financial Perfrmance Metrics. In this instance, healthcare leaders and managers wuld be able t instantly identify hw their entire institutin is perfrming frm an peratinal and financial perspective. Healthcare leaders and managers wuld be able t mve frm a 30,000 ft understanding f their institutin s perfrmance, t a 1 ft understanding f a particular prvider s perfrmance by simply drilling dwn frm the highest institutinal level dwn t the prvider level. As mst successful leaders realize, understanding current perfrmance is the first step in imprving and/r maintaining rganizatinal and financial perfrmance. Flexible, System Generated Wrk List and Fllw up Capabilities. Healthcare leaders and mangers must require flexible, system generated wrk lists that their staff can use t meet the grwing n- barding and crss- credentialing demands f their grwing rganizatin. Gne are the days f using pst- it ntes r calendar reminders t cnduct credentialing fllw up. Rather, credentialing sftware shuld drive each step in the credentialing life cycle. Further, by using a system generated wrk list methdlgy, healthcare leaders and managers can gain full cntrl ver the wrk f their staff as well as establish accuntability metrics. Rbust Analytics t Allw the User t Cnduct Data Mining and Analysis. Healthcare leaders and managers shuld require rbust analytics t easily identify peratinal, financial, r payer bttlenecks. Healthcare managers shuld be able t instantly identify which prviders are participating, nn- participating, r in prcess as well as be able t identify the financial impact (psitive r negative) f their in- prcess applicatins. Additinally, analytics shuld be easy t use and value- add. Analytics shuld help identify prcess breakdwns befre they becme financial breakdwns. Nt the ther way arund. Quality Assurance Mechanisms and Tls. Healthcare leaders and managers shuld require the ability t track, trend, and mnitr the quality f the credentialing wrk that their staff is cnducting. Currently quality mnitring mechanisms d nt exist within the credentialing sftware industry. Quality mnitring and staff feedback/training shuld be practive and n ging. It shuld nt be smething that exists as an unknwn. Prductivity Standard Tracking Mechanisms and Tls. Healthcare leaders and managers shuld als require the ability t establish and track prductivity metrics and statistics. What actins is yur staff taking n an hurly, daily, r weekly basis? Are these actins geared tward btaining a PIN faster r are they miss- guided effrts? Is yur staff wasting critical time during the day r maximizing their time fr the gd f yur rganizatin? The ability t establish and track individual staff prductivity metrics shuld make the staff mre efficient and ensure that yu are nt lsing revenue due t inapprpriate staff activities. 5
Cmbined Revenue Cycle and Credentialing Cncepts. Key t meeting the demands f ppulatin health management initiatives is t understand the financial impact f yur credentialing effrts. Current credentialing sftware tls d nt spend any time cnnecting revenue cycle and credentialing metrics. Hwever, this puts the healthcare leader at a significant disadvantage because a) he/she des nt have the crrect revenue cycle and/r credentialing metrics t track in the first place and b) he/she des nt knw what revenue they are lsing because their prviders are nt crrectly crss credentialed, r credentialed at all. Examples include: Linking grss charges t in- prcess applicatins Establishing payer perfrmance metrics such as Days In Enrllment (DIE) fr delegated and nn- delegated payers Stratifying credentialing fllw- up effrts based n prviders with the highest assciated grss charges first, and then wrking n the prviders with lwer assciated grss charges secnd. Fllwing up n credentialing tasks based n a system generated tickle timeframe as ppsed t pst- it ntes and calendar reminders Prvider Perfrmance Metrics. In rder t facilitate prvider participatin, sftware tls shuld exist which track prvider perfrmance and adherence. Hw lng did it take a prvider t sign a credentialing applicatin(s), what was the turn arund time f the signature prcess and what are the grss charges, by payer that were affected by the prvider s quick r delayed turn arund? Healthcare leaders and managers can effect mre timely prvider respnse times if they have the data shw the prvider whether they are r are nt adhering in a timely manner. Payer Perfrmance Metrics. As with facilitating prvider participatin, sftware tls shuld exist which track payer perfrmance. Healthcare leaders need the data t hld payers accuntable fr their credentialing prcessing delays. Particularly the managed care cntracting departments hused in bth hspitals and academic medical centers. The ability t maximize billable charges rests slely in the skills f the managed care cntracting department and they need as much data driven assistance as pssible when negtiating managed care cntracts fr yur rganizatin. By cllecting payer perfrmance data, and publishing that data in a clud based envirnment fr all healthcare leaders t view, healthcare rganizatins shuld be able t incent and/r negtiate imprved payer perfrmance rates and turn arund times. Prvider Scre Card Linking Clinical Outcmes With Prvider Credentials. As payers cntinue t link reimbursement with quality utcmes, credentialing sftware shuld be able t cnnect a prvider s primary surce dcumentatin verificatins (e.g., backgrund checks, criminal histry, sanctins mnitring, quality utcmes reprt cards, etc.) with their patient utcmes. There is a grwing trend t link bth primary surce dcumentatin verificatin and cntinuing educatin credits with quality utcmes s as t get a mre cmplete reimbursement picture. Frward thinking credentialing sftware vendrs will create the ability t link all three cmpnents tgether as well as prvide a value add scre card which payers and healthcare leaders can evaluate prvider perfrmance. 6
Results S What? The S What? is simple - After an assessment f the grwing demands f ppulatin health management, it is clear that as the industry cntinues t evlve, frward thinking healthcare leaders shuld demand mre frm their credentialing sftware vendrs. Healthcare leaders shuld cnduct a needs assessment f their current credentialing sftware tls and speak with their credentialing departments t see what additinal tls they believe that they need t meet the increasing demands f ppulatin health management. Healthcare leaders that d nt take the time t d s will run the risk f increased credentialing denials, frustrated prviders, and ultimately lst revenue. Thse leaders that d take the time will be well psitined t exceed the demands f ppulatin health management. Abut the Authr Sctt T. Friesen is the CEO f and has ver 12 years f healthcare experience in the hspital and faculty practice setting. Abut is the natin s premier prvider f clud based sftware and cmprehensive services dedicated t the physician credentialing life cycle. Newprt s industry defining, patent pending sftware and services enables clients t meet the peratinal and financial demands f a re- defined Credentialing Life Cycle. Fr mre infrmatin n Newprt s sftware and service slutins, please cntact 516.593.1380 r inf@newprtcredentialing.cm. 7