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.