Credentialing assistance

Wednesday, November 01, 2017 12:32 PM
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Tom Bartlett, President and CEO, 3Won

Provider data management 101: What you need to know

According to data circulated by the Physicians Foundation/Merritt Hawkins and CAQH, the average physician completes 17.8 credentialing-related applications each year complying with requirements from health systems, health plans and regulatory agencies. Studies suggest this amounts to an average of $3,000 in expense and 25 hours each year in non-clinical paperwork. That said, some independent physicians spend upwards of $10,000 a year and employ a full-time employee to manage this function. In short, it’s unnecessarily burdensome, if not arcane at times, costly and inefficient if you are an independent practitioner or a hospital administering these services for your full-time employees.

Credentialing for privileging at a hospital or health system can be painstaking and typically occurs over a 90-day time frame requiring you to provide somewhere around 350 data elements – the typical name representing three data elements – and usually occurs every two years. Health plan credentialing for enrollment requires about 180 data elements, can take more than 90 days to complete and occurs every three years. Many physicians are privileged at multiple hospitals and contract with 10 or more health plans, so it’s easy to see how complying with these requests can be burdensome.

What most physicians may not fully understand is the degree to which your data, and the accuracy of that data, is critical to your practice and revenue cycle management. Here’s why. When you submit claims to health plans they identify you using data in their master provider files, a data repository of medical professionals participating in their various health plan networks. The data in those files includes information such as your name and any aliases associated with your name such as Jack, John, J., Sr., Jr., and so on. Very often physicians may be represented multiple times in the same database and health plans use “matching” logic algorithms to ensure you are properly identified. The files also contain other data about you and your practice, much of it demographic in nature, to promote greater payment integrity and provider directory accuracy. Unfortunately, because data about you ages, or degrades, at an industry-wide average of 2 percent each month, roughly 40 percent of the data in those files is incorrect. Bad data is a systemic problem for health plans and the industry spends literally billions of dollars each year contending with the downstream effects of inaccurate provider data.

Because credentialing processes repeat every two to three years, it’s conceivable that your data could degrade by as much as 72 percent over a three-year time frame, which inevitably will cause challenges in the claim adjudication and payment process. As a result of this data degradation issue, health plans are challenged when they can’t accurately identify you, your practice location, group affiliation, correct Tax ID or product participation, and very often adjudicate claims using the wrong information such as the incorrect fee schedule; that is, the contract between you or your group and the health plan. That’s a big issue for health plans like United Healthcare, for example, which pays over $1 billion in claims daily. Claim reconciliation processes to fix claim payment errors are very costly and time-consuming. Many of these errors can be avoided if the information about you is accurate at the point of claim receipt.

Inaccurate provider data also impacts patients negatively when seeking access to care, especially when they believe you are an in-network provider only to determine otherwise at the point of access. Very often patients are given conflicting network and product participation by both the group practice staff and their health care insurance provider or health plan. In fact, 20 percent of the provider data transmitted to health plans from hospitals is incorrect.

Patients often contend with bad addresses, phone and fax numbers, and incorrect participating providers, all of which delay access to care. Indigent patients typically rely on public transportation when seeking care and it is very frustrating for them to determine your practice is actually located in a different location than the one they were given. Similarly, referrals are often complicated when a referring physician accesses inaccurate provider data and gives that to their patients.

Health plans who offer managed Medicare and Medicaid plans are now being held to a much more rigorous data accuracy standard by the Centers for Medicare and Medicaid Services, and a number of states like California are imposing material financial fines for medical directory inaccuracy. Currently, the average health plan directory has an accuracy rate of about 60 percent. The federal CMS has mandated remediation action from a number of plans to promote higher accuracy levels and patient access to care. So, make no mistake, this is a big and serious issue for health plans. The problem is how to effectively address the problem without adding more cost and burden to you and your practice. A number of organizations like AHIP and CAQH are currently piloting new programs designed to improve provider data management practices.

Like many ineffective processes, lack of communication is very often to blame for failure. The health insurance industry has not done an effective job of educating physicians and allied health professionals about their provider data and the need for greater accuracy. Moreover, increasing data and document compliance requirements have frustrated most medical professionals and further exacerbated challenges in the provider-payer relationship. What is required is greater efficiency in the data collection, management and distribution process, reducing both the time and expense of physicians in legacy data management processes.

Thankfully, many state medical and hospital associations, in alliance with 3WON, are addressing this issue directly by centralizing credentialing processes and eliminating redundancy. In Colorado, for example, the Colorado Medical Society recently began promoting a credentialing and health plan enrollment product for their members powered by 3WON, a national CVO and health information technology company. Here, CMS assumes 100 percent data and document management for practitioners for a nominal annual fee. Acting on their members’ behalf, CMS collects physician data once, updates the data daily, weekly and monthly ensuring accuracy, and distributes the data to all requesting parties when authorized to do so by each physician. All documentation is managed and completed by CMS and forwarded to physicians for final attestation. In short, CMS acts as a kind of data agent on behalf of the practice, substantially alleviating the administrative burden associated with these processes and reducing costs.

Similar to the single universal college admission application in use now in the United States, 3WON’s SmartForm application centralizes data collection and then populates all other documents and supplemental forms used by health systems, health plans and regulatory agencies for credentialing, re-credentialing, enrollment, certifications and other compliance requirements. SmartForm acts as a central data repository for medical professionals and can be updated anytime, anywhere. It also serves to manage a professional’s CV, which can be printed or distributed on demand. Medical students, for example, can populate SmartForm early in their careers and use it to store and update all pertinent data and documents pertaining to their credentials, ongoing training, certifications and specialties, publications and professional affiliations over the course of their careers. 3WON also provides helpful tools to promote efficiency in maintaining your data, which can be viewed, edited and attested to from your smartphone or tablet. Notifications are easily programmed to alert medical professionals or their proxies to upcoming requirements such as re-credentialing events, continuing education requirements for maintenance of certification, contract renewals and so on. And, if any data is changed in your profile by any entity, 3WON will alert you quickly to determine its accuracy.

Centralizing data is only one step in the data management revolution underway. Data accuracy relies on continuous updates in near real-time to ensure integrity, which in turn requires engagement on the part of medical professionals. In the legacy world it is unlikely physicians would engage if they had to provide updates to numerous entities all requesting their data in disparate formats. It would be overwhelming. Entrusting one entity, however, to collect, manage and distribute data on your behalf provides numerous advantages beginning with sole source management. In dealing with one entity, along with practical data management tools, your data can be managed in near real-time, with minimal demands on you personally. What is necessary is that physicians and other medical professionals recognize the importance of their data and how “bad” data negatively impacts you and your practice, from accurate reimbursement to patient access and practice promotion, and a slew of other realities not typically in your purview. Simply put, inaccurate data is not good for business, and medical professionals – especially physicians – should protect their profile data and ensure its accuracy. That requires the subject to be top of mind and not something considered irregularly. Useful reminder alerts are helpful in monitoring your data and minimizing practice disruption.

Legacy credentialing runs the gamut from automated to manual and relatively unsophisticated paper-based processes. A cardiovascular surgeon practicing in Chicago, where I live, may be privileged at multiple inpatient hospitals and health systems with many credentialing the surgeon independently using various disciplines, process and documents to do so. Our largest health system requires physicians to be credentialed independently at four of their 12 hospitals across Chicagoland. Approximately 20,000 physicians practice in Chicago. If we assume that the majority of re-credentialing events occur every two years at hospitals, then technically we should be re-credentialing about 10,000 physicians each year across Cook County and the six collar counties comprising Chicagoland. In fact, we credential in excess of 55,000 each year. Why? Redundancy. In supply chain management, why would you purchase 55,000 of something if you only need 10,000?

In Texas, home to some 49,000 practicing physicians, the Texas Hospital Association (THA) has partnered with 3WON to centralize credentialing data management across the state, reduce redundancy and administrative burden and cost, and, most important, ensure data accuracy and quality. Here, the object is centralization promoting efficiency. Hospitals and health systems are being encouraged to consider the necessity of numerous independent CVOs across the state and the value of a single data repository serving the needs of all hospitals and health systems where data is often managed in two distinct cost centers: Medical staff services and managed care.

THA offers credentialing and health plan enrollment services in one vertically integrated service centered on single-source data management. Moreover, a single repository represents significant value to health plans which continue to collect data from multiple sources across the state and which seek a cure to their data accuracy challenges. In turn, medical professionals rely on THA to distribute their data to all parties in Texas so that unlike the surgeon in Chicago, they deal with one entity as opposed to many.

There are approximately 875,000 practicing physicians in the U.S. today and data analyses tell us upwards of 40 percent of that data is incorrect. How much of that inaccurate data is about you and your practice? The Colorado Medical Society now has a valuable service that ensures your data is accurate and substantially reduces the administrative burden and cost associated with credentialing compliance requirements. To learn more about the benefits to you and your practice, contact Tim Smith at or (630) 328-7930.

For independent reports on data accuracy from the federal CMS, CAQH and AHIP, or for data concerning practice patterns from the Physicians Foundation/Merritt Hawkins, email



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