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.

Webinar tackles the tribulations of investigator initiated trials

Investigators should be careful to distinguish between interventional and observational studies when developing investigator initiated trials (IITs) because the distinction can effect billing strategies and budget, according a Health Care Compliance Association (HCCA) webinar, presented by Liz Christianson and David Russell of PFS Clinical. The webinar addressed key areas of focus for developing IITs, including protocol development, industry funding, and regulatory requirements.

IITs

Christianson noted there has been a remarkable renewed interest in IITs in the last two years, due largely due to industry sponsors realizing that IIT relationships are symbiotic. However, despite the renewed focus, IITs present challenges. In some cases, challenges arise from the fact that 85 percent of investigators have participated in only one clinical trial in their careers.

Protocols

Protocol development is important, particularly with respect to the articulation of an IIT as interventional or observational. Christianson noted that from reading the protocol it should be obvious whether an IIT is interventional or observational because the distinction can have significant downstream effects on budgets and billing. Christianson defined observational studies as trials where the investigator makes no intervention and allocates treatment based upon clinical decisions. She distinguished this from interventional studies, where participants are assigned to receive one or more interventions (or no intervention) so researchers can evaluate the effects of the interventions on health outcomes.

Billing

Because Medicare uses set criteria for reimbursement of trials, the objective language can be crucial to reimbursement. In observational studies, study actions should not be able to be linked to specific claims codes. Conversely, in an interventional study, actions should be linked to a specific billing code. Thus, the objective language in a study should clearly indicate what the PI’s true intent is—to treat with routine care, then collect patient data (observational) or to assign patients to specific treatment groups (interventional).

Registration

Russell discussed the registration of trials on ClinicalTrials.gov. All applicable clinical trials must be registered on the website in order to receive a unique National Clinical Trial (NCT) number, which is required on all CMS claims. Russell also covered specific data elements and registration information required by the September 21, 2016, Final rule for clinical trials (81 FR 64982). Russell reminded responsible parties that trials must be registered no later than 21 days after enrollment of the first participant and, at minimum, the applicable clinical trial must be updated every 12 months. Summary results (including adverse even information), must be submitted not later than one year after a trial’s primary completion date.

All Medicare stakeholders need to know MACRA

Although the Medicare Access and CHIP Reauthorization Act (MACRA) (P.L. 114-10) is best known for changing Medicare provider payments, its true goal is improving the quality of care delivery across the health spectrum. As a result, according to Todd Gower and Lisa Alfieri from the Risk Transformation, Health compliance sector of EY, providers must enhance their relationships and contracts with providers. Gower and Alfieri, speaking at a Health Care Compliance Association (HCCA) webinar titled “MACRA: Not just for Providers,” explained that having the proper infrastructure to obtain and organize all necessary documentation is the key to surviving MACRA.

Gower and Alfieri stressed the need for new discussions within health systems, noting that MACRA has potential to transform the health care system “equally, if not far more” than the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148). As it implements MACRA, HHS is having new conversations with stakeholders including whether the shared risk will actually improve care, and whether the current proposed criteria (see Halfway through QPP ‘transition year,’ CMS proposes substantial changes , June 21, 2017) are too restrictive. They praised HHS’ website on the Quality Payment Program as a new way to communicate with providers and other stakeholders.

MACRA is a complex law with wide-reaching repercussions. Gower and Alfieri suggested infrastructure updates, and predicted that the most-advanced providers will be seeking commercial payer partners by 2019 to maximize incentives for value-based care (VBC) payment models. Therefore, payers should create or enhance existing VBC offerings now to meet that expected need. MACRA steering committees are important to ensure compliance and update risk management programs for providers, but also for non-provider groups.