Keys to successful contracting and credentialing: honesty, questions, compliance

Contracting and credentialing are critical aspects when it comes to providers and payment. Insights and suggestions for avoiding missteps and getting the best agreement when it comes to contracting and credentialing were presented by Anna Whites and Nathan Moore, Compliance Officer at Premier Tox Laboratory, in a Health Care Compliance Association (HCCA) webinar on September 13, 2017.

Contracts

Whites defined a contract as an agreement that contains every aspect of what each party is required to do, noting that state and federal law outline contractual terms. Because different states have different laws, she recommended ensuring that the state law relied upon in the contract be the state where the individual or entity is located. She stressed the importance of reading the contract, understanding what it contains, and asking questions before signing. “Contract terms govern,” she said, and once the contract is signed, the parties can’t take the conditions back unless the contract provides for modifications as part of the terms. She also warned that the contract may require compliance with terms in other documents, for example, a provider manual.

  • Payor contracts. Provisions of payor contracts usually include services covered, provider types covered, frequency of services, and term and termination. Whites recommended providers pay close attention to these terms to ensure that they are able to meet the specifics of the provisions. Terms in payor contracts also address claims management. Providers should focus on the details of how, when, and where to submit a claim as well as how payment is made (electronically or paper), how medical necessity is defined, and how denials and appeals will be handled. In addition, providers must be aware of fee schedules included in the contract to ensure they know what they will be paid and if they are comfortable with the amount of the payment.
  • Provider contracts with health care entities. Provider contracts include the scope of services, reporting and oversight requirements, licensure and/or credentialing requirements, hours and payment, liability and insurance, and behavioral health carve-outs. Whites pointed out that when entering into a contract, parties must be aware of who is responsible for mistakes and whether tail coverage is provided. She recommended asking many questions about liability and obtaining coverage.
  • Entity provider contract with physicians and other staff. Under these contracts, the terms will include scope of services, who is in charge, who is liable, cost of services and whether the contract is with an employee or independent contractor. Providers need to determine whether employees or independent contractors are better for their organization.

In negotiations of contracts, there should be a discussion between the parties. The discussions should allow for changes and modifications. Parties should consider proposing pilots and new services. White highly recommended engaging an attorney to provide legal oversight of the contract and review the terms and provisions as well as the state and federal requirements.

Moore addressed the compliance oversight component in contracting and provided the following recommendations.

  • Ensure processes are in place to identify nonstardard terms or terms that would not be fulfilled in the organization in day to day operations.
  • Clarify any requirements that seem too rigorous prior to executing the contract.
  • Create awareness and make recommendations on how to fulfill any new requirements by coordinating with the appropriate department head.

Credentialing

Credentialing generally takes place when joining a new practice, becoming a participating provider, adding new providers to an existing group, updating information for carriers, and at the start of a new practice, Whites said. Credentialing involves collecting and verifying information about a provider’s professional qualifications, such as relevant training, licensure, certification and/or registration to practice in a health field, and academic background. Information collected before the process begins includes such documents as a copy of state licensure, a copy of board certification, proof of current malpractice coverage, a statement of disclosure of ownership and control interest statement, and a summary of any prior malpractice or disciplinary action. During the credentialing process, payors assess whether a provider meets certain criteria related to professional competence and conduct, Whites explained. Relevant factors may include location, cultural diversity, ability to speak other languages, treatment provided to children, availability, crisis training such as ability to provide care in emergency and address behavioral issues, and ability to refer and admit (to other hospitals or entities).

Whites recommended providers to be aware of specific degree requirements of the payor or network, state requirements regarding credentialing, and billing regulations that may limit reimbursable services to certain provider types. When permitted, Whites suggested submitting a resume. She also stressed that it is a provider’s right to: (1) request a status of the application, (2) review information that the payor used to deny or defer credentialing, and (3) correct any inconsistencies between the information obtained by the provider.

Credentialing issues

Whites and Moore identified issues and areas providers must be aware of to ensure that they are in compliance with requirements. Some of those areas include:

  • Cooperate in CMS audits and sites visits to ensure providers are properly enrolled, credentialed, and operating. Not cooperating may result in revocation of provider agreement.
  • Maintain compliance with payor requirements, good intentions are irrelevant to CMS.
  • Regularly review credentialing and licensing to ensure they are up to date.
  • Screen for excluded providers on available sources, prior to employment of individuals or contracting with vendors and maintain screening records for seven years. Develop a removal and notification process.
  • Ensure that providers are properly enrolled in Medicare and Medicaid enrollment systems.
  • Be aware of billing issues such as out-of-network denials, nonpayment for new provider types, and services that payors will not pay for because they were provided by a noncredentialed provider.
  • Ensure that providers are aware of coverage and payment rules regarding telemedicine.

Conclusion

Whites emphasized transparency and clarity in responses in contracting and credentialing. She stressed that providers must be honest because information is much more readily available to parties seeking it, for example, from the national databank. She noted that there are severe penalties for errors in credentialing and pointed out that CMS can exclude providers for multiple years. On the other hand, she said there are unintended negative consequences related to credentialing that arise from such things as not updating an address, not disclosing working with an excluded entity, and being responsible for a prior owner’s bad actions.

Continuous improvement in compliance can proceed systematically

Provider organizations should not dread continuous improvement in compliance and can apply several techniques to simple problems to bring about simple solutions. In a Health Care Compliance Association (HCCA) webinar entitled “Continuous Improvement in Compliance,” presenter Alan Wileman, Corporate Compliance Manager at Shriners Hospitals for Children, discussed applying principles from Lean and Six Sigma to improve function and eliminate waste in company functioning.

Improvement methodologies

Wileman noted that compliance goals evolve, and that the OIG uses subjective terms for compliance matters such as “reasonable,” “appropriate,” and “meaningful.” What is meaningful or reasonable for one compliance area may not be sufficient for another area or at a later date. Overall, lowering risk is the focus of many compliance tasks, but there may be better ways to bring about that desired result.

Improvement methodologies such as Lean, Six Sigma, and project management have been proven to streamline procedures, eliminate waste, and bring value. Lean ideas and practices originally derived from industrial manufacturing, and have one main purpose: eliminating waste. Six Sigma is often grouped with Lean concepts, and focuses on eliminating error waste by removing variation in procedures. According to Six Sigma, there may be multiple ways to do the same thing, but there is always a best way to do so that reduces variation. Project management focuses on clearly defined terms, roles, and goals in order to successfully complete a project—a non-routine operation with a definite beginning, end, and goal.

Waste

According to Wileman, there are several types of waste. Among those discussed included talent, inventory, waiting, defects, and motion. Compliance departments should ensure that a particular task is being completed by the employee whose strengths play to that area. Motion waste comes from requiring employees to move around the work area too much in unnecessary ways, when communication could effectively be conducted in a non-face-to-face manner or when a workplace could be reorganized to provide a better workflow.

Toolkit

Reorganization also applies to employees’ personal workspaces, which should be uncluttered and only contain the necessary, crucial supplies. Wileman suggests adding the “5S” strategy to an operation’s compliance toolkit. The five elements are: sort, set in order, shine, standardize, and sustain. These elements ensure that a workspace is stocked as necessary, arranged to promote efficiency, neat, organized consistently with other spaces, and sustained in this manner. For tasks, the “DMAIC” acronym is made up of the elements define, measure, analyze, improve, and control. Once a problem is clearly defined, it is easier to map out the process, identify the cause of the problem, implement the solution, and maintain the solution over time.

Essential resources for health care providers & attorneys during hurricane season

Hurricane season has arrived and health care providers in affected areas are focusing on providing services to injured individuals and rebuilding damage to facilities, but not necessarily on compliance with Medicare and Medicaid laws and regulations. To assist providers, federal and state agencies are temporarily waiving some regulatory requirements and providing other emergency services. While active hurricane recovery efforts are underway, Health Law Daily will feature links to federal and state resources.

Federal information:

State- and commonwealth-specific information:

How to avoid coding pitfalls for ambulatory services billing

Ambulatory services documentation offers compliance challenges as complex as inpatient services documentation that providers need to be aware of to avoid potential compliance risks while documenting for billing. Ellis Knight, M.D., Senior Vice President/Chief Medical Officer, of the Coker Group, focused on ambulatory coding in an HCCA webinar titled “Clinical Documentation for Compliant Coding—It’s No Longer Just an Inpatient Issue.”

Clinical documentation improvement

Knight noted that coders “speak” a different language than clinicians and therefore clinical documentation improvement (CDI) has been mainly a translational process. Specifically in relation to medical diagnoses, translating what a clinician may write down in the clinical note versus how the coder interprets the clinical note for billing purposes. Historically the focus has been on inpatient documentation, especially documentation to justify diagnostic related group (DRG) assignment and capture of major complications and co-morbidities (MCCs) and complications and co-morbidities (CCs). As a result, the “problem” is that reimbursement occurs with parties arriving at the same diagnosis with different billing codes.

Ambulatory documentation

As such, ambulatory documentation is equally as complex as the inpatient documentation arena, involving thousands of codes. A major complicating factor is that time-frame and volume of patient encounters makes ambulatory CDI a much different work process than inpatient CDI. Knight noted that among the many compliance risks associated with ambulatory CDI, documentation must support: (1) medical necessity of services rendered (CPT codes); (2) specific services and level of care provided to the patient (CPT and HCPCS codes); (3) diagnoses (ICD-10); (4) severity of illness and clinical complexity (HCCs); and (5) quality of care rendered (HEDIS).

For medical necessity, the clinical documentation must justify the ordering of tests, performance of procedures, referrals to specialists or consultants, prescribing of medications and other activities which payers must cover. It must document services and level of services performed, as errors leave practitioners at risk for overbilling the carrier which could result in treble damages under the False Claims Act. Moreover, Knight stressed that it is not enough to just document. HCCs must be documented on an annual basis and addressed, i.e., monitored, evaluated, assessed or treated, in order to be captured. In regards to quality of care, the clinical documentation must include provision of certain quality of care measures, e.g., immunizations, tobacco use, smoking cessation counseling, BMI measurement, obesity counseling, preventive care (colonoscopy, mammography).