Episode 31
Allison Jones
Welcome to the Therapy Matters podcast, your one-stop resource for expert insights and advice on everything therapy and rehab. I’m your host, Allison Jones. Today, I’m joined by our two-time guest, Bill Sillar, the Head of Business Development at Raintree. Welcome back to the show, Bill.
Bill Sillar
Thanks, Allison. Thanks for having me back.
Allison Jones
It’s great to have you back, Bill. Before we begin today’s session, could you introduce yourself? For those who might not have heard your previous session or need a quick refresh, please tell the audience a bit about your background and what brings you to the show today.
Bill Sillar
Absolutely. For those who don’t know me, I’m Bill Sillar. As Allison mentioned, I am the Vice President of Business Development here at Raintree. One of the reasons Allison wanted to speak with me is because of my experience in the credentialing space. I spent four years with a software provider that assisted hospitals and health systems in aligning with solutions to aid in the credentialing and payer enrollment process.
Allison Jones
Excellent. That’s what we’re going to focus on today. It’s a really important topic, something that’s near and dear to both of our hearts. I’ve also spent time at a company that focused on credentialing enrollment. We’re going to talk about it. Provider and credentialing enrollment is an absolute necessity when running a successful practice. It’s essential, but it can also be a bit of a hassle, right?
Bill Sillar
Absolutely.
Allison Jones
It’s kind of like taxes. When you bring it up, you can almost feel the air being sucked out of the room. You have to do it, but nobody likes doing it. When we talk about credentialing, it seems like a relatively straightforward process, right? You send some information out; you want to verify a physician or provider’s qualifications. You’re looking at their work history, their education, their certifications, their licensure, and so on. It gets reviewed, goes through a thorough vetting process, and then it comes back confirmed. Then everything’s great, and you start getting reimbursed. It sounds simple, right?
Bill Sillar
Not so simple.
Allison Jones
It’s not as simple as it seems. The reality is that it’s not always easy because there’s a variety of information requested, making it a very detail-heavy process. There are many mistakes and pitfalls. There are many things that can trip someone up when going through the credentialing and enrollment process.
So, we’re going to dig into it. We’re going to discuss some of these common mistakes, why they happen, and share some tips and tricks for avoiding them. Does that sound good?
Bill Sillar
Absolutely.
Allison Jones
Alright, excellent. Let’s dive in. My first question for you is, let’s start right from the very beginning, what is credentialing?
Bill Sillar
Credentialing is one of those blanket terms that can mean several different things. It can be interpreted differently based on who is listening. When I say ‘credentialing’, some people might interpret it as ‘payer enrollment’. A physical therapist, or any therapist, needs to be enrolled with a payer to send out charges and claims. To get reimbursed, they must be enrolled with that payer. Some people refer to this process as ‘credentialing’, ‘payer enrollment’, or ‘payer enrollment credentialing’.
Another aspect of credentialing is ‘primary source verification’, which is similar to a background check. As you mentioned earlier, it’s about ensuring that a professional has the necessary credentials to perform their therapeutic duties. It verifies that there are no blemishes on their record and that they are authorized to provide care in their state, setting, and specialty.
Allison Jones
There are two distinct processes: credentialing and enrollment.
Bill Sillar
Exactly. There’s the process of primary source verification. Following that, there’s the payer enrollment process.
Allison Jones
Okay, you sort of touched on it with credentialing. So, is credentialing a compliance issue?
Bill Sillar
It definitely is a compliance issue. Allison, let me tell you a quick story that will kind of bring it home to everybody. So, we’re on a podcast. I’m going to mention another podcast. This is like that Leonardo DiCaprio movie where he was in dreams all the time. Yeah, but there was a podcast out there called Dr. Death, and they’ve actually made it into a mini-series on Peacock.
Dr. Death, Christopher Duntsch, was a neurosurgeon who was working in a hospital in the Dallas-Fort Worth area. Neurosurgery is a very high-ticket item. When we’re talking about the types of surgery that he was doing, the hospitals were making about $60,000 in profit off of those. So, that is just a cash cow when we’re talking about health systems that want to get those types of neurosurgeons in the door to really help their cash flow.
He came from Tennessee into the Dallas-Fort Worth area. When they were doing his primary source verification, looking into his background, they didn’t question enough things. One of the red flags on his CV was that he was magna cum laude from St. Jude Children’s Research Hospital with a doctorate in microbiology. However, the program did not exist when he was attending there at that time. This red flag should have been caught in the primary source verification, indicating that this person was lying to get the job.
One of the first things you would be able to do in that primary source verification step is making sure that this person has the background that they claim to have. Dr. Duntsch did not have the proper schooling and did not have the proper experience to perform these types of neurosurgeries. For example, in his medical training, he had only participated in 100 surgical surgeries. He should have participated in more than 1,000 while he was being educated. So, he only had 10% of the experience that he should have had to practice medicine. This is another thing that should have been caught in the primary source verification steps.
What happened is that during the course of about a year, there were 38 patients with whom he was practicing medicine. Out of those 38, 33 were injured. He performed surgeries on them, and the outcomes were terrible. Some patients were paralyzed, some could never walk again, and some had paralysis on parts of their face.
The outcomes were really poor because of this. So, when you’re asking if this is a compliance issue, there’s a huge risk. The hospitals that had Dr. Duntsch performing surgeries in their facilities were sued for hundreds of thousands of dollars. There’s not only a reputational risk if you hire and credential the provider incorrectly, but there’s also a real financial risk. There’s a huge compliance risk with not putting the right time and effort into credentialing.
Allison Jones
When you bring a new therapist into your practice, you want to make sure that they have the proper schooling. They should have the proper credentials to be treating your patients. You want to ensure that you’re giving your patients the appropriate care and the level of treatment that they deserve.
This is not only to treat your patients correctly but also to protect your practice, your investment, and your financial future. So, you have that primary source verification. That’s the credentialing piece of it.
Then, in order to get paid, you have to do the payer enrollment piece.
Bill Sillar
Absolutely. Once the primary source verification comes back with no blemishes, and the person proves they are who they say they are, we’re able to confirm that their licensing for all the different states looks good, their NPI checks out along with all the other different pieces of information that we’re having to verify, then we can start going through the payer enrollment process. We can go through committees and panels to ensure that this person will be able to send out those claims to the payers and get paid. That’s what we aim to achieve.
Allison Jones
Excellent. Having the experience that you’ve had in the credentialing space, you’ve picked up a few things here and there. You’ve recognized some patterns and some common mistakes. We’ve talked about a few of these in our prep session before this, so we want to talk about a few of them today.
The first one is that it’s really easy to have unrealistic expectations about how long the credentialing and enrollment process takes. So, talk to us a little bit about how long does it actually take and why does it take as long as it does.
Bill Sillar
If you’re a new therapist that’s coming along, it could take about 30 days to go through the whole process. It could take as long as 60 to 90 days to get fully credentialed. Some payers could take six months to go through the whole payer enrollment process. You might be enrolled with some payers, but for certain payers, it takes longer.
The reason is that when you think about all of the different payers and all the different states that are out there, there are different rules for many of these. If you don’t know the rules for a particular state, or if you don’t know the rule for a particular insurance, it’s really going to be difficult because there are a lot of complexities and things that you have to remember when you’re able to submit these things.
Also, Allison, one of the things that’s really at risk is that if you have a provider that’s sitting on the sideline. So, 30 days is bad, but that’s the normal time it takes to ramp up. We’re talking 60 or 90 days that our providers are just sitting there on the sidelines not seeing patients. So, number one, there’s a shortage of therapists right now, and patients are not able to connect for care, which is a huge problem. The second piece is that you’re going to be short-staffed. You’re not going to be able to get out there and get the type of revenue that you’re looking for.
We’ll use just quick math here. If we’re thinking that the average physical therapist does about 100 to 200 visits per month, and if we’re thinking that the average reimbursement would be about $100, you’re looking at a $10,000 to $20,000 loss if that provider is sitting on the sidelines and you’re not able to effectively get that provider credentialed and enrolled fast enough. If they’re just sitting on the sidelines for 90 days, you might be talking about a $30,000 to $60,000 loss, which could really hurt. And then we’re not even talking about you having to pay them or to pay their salary and things like that while you’re waiting for them to be credentialed.
Allison Jones
I also want to discuss the enrollment process. As I mentioned earlier, there are many manual processes and a significant amount of paperwork involved, especially on the enrollment side. There are various applications that need to be filled out for each payer. One common mistake we often see is not allocating enough staff to handle this paperwork. This can lead to errors on the paperwork, resulting in rejections from the payer. Then, you have to go back, correct the errors, and resubmit, which can cause delays. What was initially a 60 to 90-day process may extend to 120 days. What’s the best way to handle this paperwork? How can we reduce errors, streamline the process, and complete it in the most efficient and quickest way possible?
Bill Sillar
I’ve worked with a number of groups, and what I’ve seen is that the ones that have some sort of database that keeps them straight on where everybody is in that process are the most efficient. So hopefully, they’re not using paper.
I’ve seen a number of groups, both large and small, that are still using paper or not using a credentialing system. That’s where there’s a lot of struggles because if you’re using Excel or Access or whichever, there’s still a lot of manual tasks that you’re having to do and remember a lot of those things.
We had mentioned those rules. You’re still having to remember those rules that, okay, this is Aetna for this state. So I’m going to have to do X, Y, and Z for this provider. And then for this state, I’m going to have to do X, Y, and Z. So you’re really having to remember different rules based on all of those things if you’re using paper or using Access and not a credentialing system.
To go through the credentialing process, which I believe was one of your questions, there are several steps. Let’s break it down. If you’re a brand new PT or a new therapist to an organization, the first thing we need to do is gather your information. This usually happens right after you’re hired or during the hiring process when they send you a large packet. This packet will require you to write out all your information, such as your NPI, your previous workplaces, and any other information we would need for the primary source verification process.
If you have a credentialing system, one of the advantages is that you can digitize these packets and letters, which can reduce the time and effort required from your staff and automate the process. While this might not automate the process from the provider’s perspective, your staff will be able to easily review the information and identify any discrepancies. This also eliminates the need for someone to manually transcribe the handwritten form into a system.
Once we receive all the necessary information, that’s when the background checks and primary source verification processes begin. We strive to ensure that the information provided by the therapist aligns with our records. We also conduct any necessary background checks to ensure that no one is evading issues by moving from one state to another. For instance, is someone moving from Tennessee to Texas due to negative experiences that they’re fleeing from? We are thorough in our background checks because, when providing care, we want to ensure that we are assigning the right professionals to patients to guarantee the highest quality of care.
Once all of that is complete and the primary source verification returns positive results, we begin the payer enrollment process. This involves sending out necessary documents to insurance groups for the enrollment of the provider. We also prepare any panels that may be needed during this process. If any issues arise during the enrollment process, we collaborate with the insurance companies to ensure they are resolved. We strive to address any problem areas and ensure a smooth process.
When we talk about the 30-day period, it’s reminiscent of the show “24” – a reference to a show from 2002, quite timely. But the clock is ticking. As soon as the provider starts working for you, the 30-day countdown begins. Any time beyond that could mean money out of your pocket if you are a therapist group.
Allison Jones
Absolutely. You want to make the most of that and get it done as quickly as possible.
Bill Sillar
One other thing, Allison, that I should talk about too, is that we’re discussing this from a net new perspective. However, you also have to re-credential, and so that process does start all over again every so often. You have to be aware of that. That’s why it’s really important to make sure that you have some sort of system or process that’s tracking who’s credentialed, who’s doing this, and also monitoring those licenses.
If you have a state license, or if you have a provider practicing medicine or therapy in a few different states, it’s crucial to ensure that all of those licenses are up to date so that there’s no gap in care.
Allison Jones
One of the other common mistakes we often see, and you’re leading me to it, is the failure to keep their CAQH current. This is something we frequently observed with our credentialing team, and I’m sure you guys have seen it quite a bit too. The CAQH often lapsed, causing numerous problems, especially during the re-credentialing period. We saw many denials due to these lapses. What are some tips or strategies to ensure that the CAQH stays current?
Bill Sillar
Actually, Allison, let’s bookmark this because you mentioned denials. There’s a significant source of denials when you think about it. If your provider data is flawed, it’s going to disrupt all of your downstream data. Often, we say that a large source of denials is registration, which is just from the patient’s side of things. However, this is even before that, further upstream. So, if you want to ensure that you’re impeccable and that your margins are improving, then you’ll want to ensure that you have an excellent enrollment process and a robust credentialing process.
For those unfamiliar with CAQH, it stands for the Council for Affordable Quality Healthcare. It’s a non-profit organization established by some of the nation’s leading health insurance companies. It holds information for 1.3 million providers in the United States, functioning like a large databank of information.
One of the advantages of having your information in CAQH is the ease of accessing that information. This is particularly beneficial for individuals who are at multiple locations. For instance, if you were a PT and moved to another organization, they could retrieve your information from CAQH, providing a head start to the data gathering process. It’s crucial to keep your CAQH information updated because, as mentioned earlier, any discrepancies could lead to downstream issues such as denials.
Allison Jones
If you fall victim to some of these common pitfalls or mistakes, what is the impact on your practice?
Bill Sillar
Oh, there’s a gigantic pitfall. As we were discussing earlier, new providers are going to feel it as they will be sitting on the sidelines, waiting to get into the game. This waiting period will eat into the budgets of various practices while they wait for these clinicians to get credentialed.
Another aspect is the downstream effect, which will lead to denials. If we have inaccurate provider information, it will affect the claim information, resulting in denials by the clearinghouse.
Allison Jones
I think I was reading a statistic the other day that across the entire healthcare spectrum, not just PT, but the entire healthcare industry, 42% of denials are credentialing-related. Across the entire healthcare industry, billions of dollars are related to credentialing-related issues. It is a significant but solvable issue. Really examining your credentialing process and ensuring that it is on point and that you have re-credentialing under control will help you manage that denial process. It will ensure that it’s clean, and then you can delve into other areas that might be causing you denial headaches. We’ll just lead that right on to the next question: how do you do that? How do therapy practices make the credentialing process a little bit easier?
Bill Sillar
Great question, Allison. One of the things that this is going to impact, just to circle back to the last question, is growth. What I typically see in a healthcare organization is that the billers are usually the ones doing the credentialing. You might not have a dedicated credentialing person, so if someone’s main job is billing, but they’re also doing the credentialing on the side, they have to remember all those rules. This really limits your speed in moving forward with many things.
What I’ve found is that with dedicated people for that, as you grow larger, you’re going to need a dedicated process. If you don’t have a dedicated person for that, make sure you have a documented process on how you’re going to go about it for all these different insurance companies and states. This way, you can get these providers credentialed or re-credentialed as quickly as possible.
Having a documented process is one of the first things to ensure. Make sure that the data-gathering process is as quick as possible, wrangling that provider information upfront and getting it entered in. If you’re not getting that information on day one, and it’s taking two weeks to find all that information, it can really weigh you down. What I normally suggest is, during the hiring process, if you have a candidate who looks like they’re going to get hired, let them know, “Hey, we’re going to need all of this information.” So, on day one, we need to have this provided to us so that they’re not scrambling two weeks in looking for that. This is because it’s going to delay the process by 45 to 60 days if they’re still scrambling for that information two weeks in.
Allison Jones
Are there technologies or tools that can help streamline the process further?
Bill Sillar
Absolutely. When we’re talking about automatically pulling in information, there are many systems out there that can do this. If you’re looking to verify an NPI, it will verify that NPI or pull in information from CAQH so that you can already have it in your system, reducing your reliance on manual input. License monitoring is another feature; you can have a system that checks different states’ websites to ensure that they’re compliant in states like Indiana and Illinois. This allows for consistent checks without having to manually visit their website. It automates the process to ensure that the license is valid for a whole year. There are many pieces of technology available that can streamline this process.
Another thing that is really important is making sure that you have some sort of integration with your EHR and your billing system because, like we were talking about before, if you just have a downstream system that is not connected to this, then you might make an update in your credentialing system or in your provider data management system and it’s not going to update that billing system or it’s not going to update that EHR, and your data is going to be out of sync.
I’ve seen several times in businesses where you have multiple systems that are just not communicating with each other at all, or they’re not communicating enough. This lack of integration takes time out of people’s days. They think, ‘Okay, I have to update the provider data management system. I have to update the billing system. I have to update the EHR.’ This is where there’s a lot of room for denials and other issues we were talking about.
Allison Jones
Are there other aspects of the technology or tool, apart from the integration component, that a practice should consider to simplify their credentialing process?
Bill Sillar
Yes, it’s beneficial to establish a connection with CAQH. This allows you to pull in information or set up some form of push mechanism, which will be particularly useful for your location. This is one less thing to worry about in the future as it eliminates more manual tasks from your staff’s workload. Moreover, reducing manual tasks also decreases the error rate.
Allison Jones
Excellent. Alright, Bill, do you have any final thoughts for our audience today?
Bill Sillar
The credentialing system, as you mentioned, is like your taxes. You’re 100% right. If you don’t pay your taxes, you go to jail. I’ve never really tested that, but that’s what they tell me, and so that’s a rule I live by. It’s the same with credentialing. We talked about Dr. Death beforehand. If you don’t take the credentialing process seriously, there are major ramifications. Not only is it going to be financial, as we discussed extensively, but there’s also a provider burnout phase happening right now across the country. If the credentialing process doesn’t go well, a provider could just say, “This isn’t the place for me,” hit the brakes, and start looking somewhere else.
Another issue you might encounter is related to your reputation. Consider this: if a provider does something that results in a poor outcome for a patient, or if a patient has a bad experience and the provider had a blemish on their record beforehand, it’s going to reflect poorly. With the prevalence of social media and news today, everything gets out there. This could exponentially harm a group that’s trying to survive or thrive.
Allison Jones
Excellent. All right. Well, Bill, we’ve run out of time for today, but this was a great conversation. I love discussing credentialing and enrollment, and it seems like you do, too. So, thank you so much for joining us today. I really appreciate it. I also want to thank our audience for tuning into the Therapy Matters podcast, your one-stop resource for expert insights and advice on everything related to therapy and rehab. We look forward to seeing you on the next episode.”
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