Hey, I’m In Network, Not Out of Network!
Claims suddenly out of network? This discussion explains why credentialing lapses, CAQH, and plan enrollment gaps cause denials, and what chiropractic physicians must monitor to stay in network and get paid.
Transcript:
Marc:
So I’m talking to Brandy Brimhall. Brandy is the CEO for Practisync. Practsync is the management service organization. But really it’s a billing it’s a billing company that helps our doctors and is wholly owned by the Illinois Chiropractic Society, by the way. So Brandy is an extension of the ICS team, and so she’s here helping us out today to talk about some credentialing challenges. And one of the things that I hear, and I’ve heard quite a bit from some of our doctors, really, over the last 12 months, we’re seeing a ramp up from from insurers in some areas, but where a doctor calls and he’s like, Marc, I’ve been in network for years, and all of a sudden, now they’re telling me, I’m out of network. They’re processing my claims out of network. There’s other challenges. Brandy, what are you seeing in the world of credentialing as it relates to these kinds of problems with a provider?
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Brandy:
Absolutely, so in the world of credentialing, when the credentialing service gets calls like that, or when we do in our offices most of the time, the clinics say payers are doing it wrong. I’ve been billing the same way forever, and now they’re processing my claims wrong. We call them, we appeal, and these claims are still being processed out of network most of the time, and that’s probably 95 plus percent of the time. It isn’t that the payer is receiving and processing those claims improperly. Now processing your claims out of network instead of in network, the more likely possibility is that your business or the provider is not enrolled with that particular plan. So keep in mind, if you were enrolled a long time ago, you would have been, or even recently, you’re only eligible for enrollment for a certain set or type of plans, and there are rules for different types of plans, your Medicaid, your Medicare advantages, your commercial plans, and so on. So if those aren’t part of your enrollment, then those are out-of-network plans for you until those are added to your existing contract. So keep that in mind. First thing to check, rather than assuming the payer messed up, is to determine whether or not you’re enrolled with that plan. And then if it’s one that you continue to be seeing, perhaps you’d like to add that to your existing contract. And you can go through and do that with the credentialing service and add those existing or those new plans to your existing enrollment.
Marc:
Yeah, so they could do this on their own. Of course, each payer has their own process. Blue Cross, Blue Shield of Illinois. A lot of that’s done through Availity and also CAQH, which, incidentally, we’ve run into this before, and actually received a call over the last three months on this specific issue where someone did not upload the CAQH their required Med, mouse certificate, and so they didn’t upload their certificate. CAQH continued to ask and warn, and the doctor didn’t, didn’t get it nailed down. It could be that they did not receive it via email. So I’d also encourage you to check your CAQH status, maybe once a month. Have a team member that goes out and does it, or, quite candidly, you can do it in the evenings as you’re trying to break down and relax a little bit. Just jump out and make sure you don’t have any flags or warnings from CAQH. But make sure that you keep that up to date, because if you miss what happened in this particular case is they reported it to Blue Cross, Blue Shield of Illinois, who, in turn, terminated the provider out of their network because they weren’t in alignment with the requirements of the contract. And so then the doctor had to go through the whole credentialing process again. They still had to upload the certificate. They still had to beg Blue Cross, Blue Shield for grace. They still had to go through the recredentialing process, and it can be a bit of a challenge. You can do it on your own, but we also know that that can be a challenge from time to time. And quite candidly, you’re busy seeing patients, which is, you could always ask for some professional help, too. But what else are you seeing in this area? Brandy, anything?
Brandy:
On that front, I would say it’s almost like a parallel too, because every enrollment we have is required to be maintained, and so your CAQH, your Availity attestations, so that too can cause the used to be in network, and now suddenly I’m processing out of network, so making sure that we have our fingers on the pulse of keeping your existing enrollments maintained. Otherwise, usually when clinics find that suddenly claims are processing different than they realize. Usually, they think the payer messed up, when in reality, it’s some kind of oversight or issue on behalf of the clinic. So those are a couple of things on that front. Really, the main thing with the credentialing and enrollment on this particular topic is making sure that you know your plans when you’re enrolled. You’re not necessarily enrolled with everything. For example, in order to be enrolled with Medicare Advantage, if you wanted those as part of your enrollment, you’re obligated to first be enrolled with Medicare because your Medicare PTAN Number has to go without application. So there are different rules and nuances with every single payer in the enrollment. So just don’t forget that that’s an important part, really. One of the part of the bedrock, I guess maybe I would say, of the revenue cycle system, is making sure that your enrollments are properly established, and then, of course, your software set up so that you’re billing out in the way that you’re enrolled, so your claims can process properly.
Marc:
Yeah, exactly. And I would say it’s also important, especially with all of the new laws centering around provider directories, that you make sure that that information is maintained and up to date, and they require that you do that at a minimum every 90 days. Again, I would encourage you to do this every month to make sure that you don’t miss one of those required deadlines because they’re being dogged about. And the reason why, just so you know, and I don’t stick up for insurance companies, trust me, there aren’t many people that dislike insurance companies more than I do. But here’s what we have found, is they’re being required by regulation, by the law, to maintain these directories, and so they’re actually passing it downstream to the providers. So they have their own obligations, and they have their own fault at this, and there’s a lot there. And so what they’re doing is they’re trying to pass the buck, and they’re trying to blame the providers for this. And the way they’re doing it is saying, Hey, we’re asking the providers to update this information. So when the providers don’t update it, then they have a reason to say, hey, they’re not doing it. Our action, in order to maintain a more accurate directory, is then, for those who aren’t verifying it, then we’re just kicking them out of network and removing them altogether. So if they’re not verifying it, they’re not in network, and so we’re going to kick them out. So that is why keeping up to date with that is super important. And we’re also seeing that happen. Are you? Are you seeing that with any providers, Brandy?
Brandy:
All the time, yes, because that those attestations are part of the provider screening and ongoing re screening, and that’s included in the provider contracts that you sign that in order to access the network benefits, you’re going to agree to maintain your enrollments to help the the network maintain their compliance, and ultimately your compliance with those guidelines, so that you’re eligible to access the benefits you always want to be in the best position to efficiently get paid properly for what you’re doing, and to keep the money that you have been paid. And this topic that we’re talking about now is certainly one component to all of that.
Marc:
Yeah, all that’s super important, and hopefully this helps keep you in line and with your credentialing with the insurance carriers that you want to be enrolled with, and we’ll catch you next week.
