Blog: Delayed Credentialing – The costs of a complicated payer enrollment process

The phrase “Time is money” isn’t a new concept, but there’s a good reason the cliché has stuck around as long as it has: It’s true.

For those involved in the payer enrollment process that connects providers and payers in credentialing, “time is money” is particularly true, because the many tedious tasks that have to be performed to complete each transaction take up more time than they should.

For providers and staff that are already stretched too thin, provider data management processes like credentialing are often a driver of unnecessary administrative burden. This is particularly true for payer enrollment – a multistep piece of credentialing involving many players, which creates a $2 billion administrative waste problem.

The Current Payer Enrollment Environment

Payer Enrollment – sometimes called provider enrollment by payers themselves – is the crucial first step in the payer-provider relationship. Without it, providers can’t begin to bill for services or be paid in a timely fashion, so they must devote a significant amount of resources to the enrollment process.

The most exhausted of those resources is time. With each payer requiring specific forms, sent in specific formats, and with those forms often completed manually, it’s a tedious grind that eats up valuable time for clinicians and staff. There are multiple steps in the process that have to be repeated for each new payer-provider relationship, and steps often have to be repeated even within a single relationship due to errors and updates.

While filling out forms may seem like a simple administrative task, the lack of consistency in the processes used by payers, clearinghouses and other third parties involved creates many opportunities for failure. In the majority of cases, Payer Enrollment involves as many as eight distinct steps:

  1. Provider onboards and starts the credentialing process for a new clinician.
  2. Provider informs the payer that they are interested in credentialing.
  3. Provider manually completes a variety of forms.
  4. Payer receives a provider’s application.
  5. The 90-day-plus review process begins.
  6. Payer performs a separate and different verification.
  7. Payer accepts provider application.
  8. The process repeats again in two years to follow the National Committee for Quality Assurance (NCQA) credentialing standards.

The result of such a drawn-out process is a fragmented system with little to no clearly defined ownership of the data and roles involved. The manual tasks involved in the process also prevent smooth transactions, from the requirements for “wet signatures” to the use of snail mail to submit material. The result of those elements is the increased risk of “bad data,” which further complicates the process by creating inconsistencies and repetition. And with no single source of truth to serve as an authoritative resource, errors and repeat processes continue to pile up, costing significant dollars and time.

It’s a problem that is only getting worse. CAQH estimates that providers are leaving as much as $9.5 billion in savings on the table by not automating their administrative processes. Payer Enrollment is a significant percentage of that potential savings – according to CAQH, the process costs payers as much as $2.3 billion per year – costs that are largely passed on to providers. An automated solution that streamlines the process could result in savings of as much as $1.7 billion.

Solving the Problem

The inefficiencies and issues in Payer Enrollment (and credentialing as a whole) are not new. There are some existing products designed to alleviate specific problems, such as third-party solutions, health information exchanges (HIEs), and payer portals. Yet those measures often only collect, cleanse or facilitate better data management – it’s the rare product that will fulfill all three needs.

In our new whitepaper, “Integrated, Connected Payer Enrollment,” we take a deeper dive into the problems with Payer Enrollment – problems that the Madaket Platform is designed to solve by creating an automated, streamlined system with which providers, payers and clearinghouses can more efficiently and effectively manage data. Expectations for value-based care and web-based patient portals are intensifying, and the threat of legal liability hovers over any practice that does not successfully manage its data. A single solution that can make that management more accurate and efficient is a significant need for the healthcare industry. The Madaket Platform is that solution.

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