While the prevalence of electronic systems for payers and providers to exchange data and information is increasing, too many of the systems still require manual completion of forms and tasks. “Electronic” is not the same as “automated,” and the manual work required to use the systems creates more errors, which leads to delays in providers getting paid for care.
Fortunately, the majority of the delays – whether it be for provider enrollment, credentialing, or other common payer-provider transactions – can be attributed to a few common issues that can be avoided with better processes and technology.
- Data entry mistakes
Manual work is subject to human error such as typos, putting the wrong information in the wrong box, and illegible signatures and other handwritten information. One of the most common mistypes on forms, according to clearinghouse Greenway Health, is ZIP codes. Names, duplicated addresses, invalid special characters and other common typos and errors can easily foul up paperwork processes with payers.
- Discrepancies in the payer system
Providers aren’t the only source of problems; payer updates can cause issues too. This happens with taxonomy codes for provider categories and specialties in credentialing processes. These code sets are updated regularly by payers – Medicare, for instance, updates its Healthcare Provider Taxonomy Code Set twice a year. With each update, providers and clearinghouses have to make sure that the code information in provider profiles still lines up with the payer’s current set.
- Poor update notification
An average month sees changes to 2.5% of all provider demographic data doctors change addresses, last names, and phone numbers, or they complete the recredentialing process. In theory then, provider profiles should be updated in payer systems every month, but an average of 30-40% of provider data on payers’ records are incomplete or wrong at any given time.
Providers and their clearinghouses are required to notify payers of these changes in a timely fashion; Harvard Pilgrim, for example, requires 30-60 days’ notice on changes. If payers aren’t notified within the time parameters they mandate, paperwork can be denied or have to be restarted.
- Having the wrong forms
Many times, it’s not the data that is wrong – it’s the forms. Payers that periodically update their forms may not always adequately notify providers and clearinghouses with whom they work. An outdated form, even with the correct information, can slow enrollment, credentialing and other approvals for weeks. Routine checks to ensure the latest forms are in use (plus a full refresh every time a payer updates) is the best strategy for keeping everything current.
- Errors in attachments
Payers can require many supporting documents in addition to the forms, supplied by different entities, especially for the credentialing and enrollment processes. Supporting documents should always be reviewed for accuracy and alignment with the information in the primary forms before they are transmitted. For example, W9s, voided checks, driver’s licenses, and other documents should be checked to ensure the latest versions with information that matches the forms are being sent to payers. The extra time and energy spent before the documents are sent out is dwarfed by the resources wasted if supporting documents are rejected and a process has to be needlessly repeated.
- Not checking in
There is a near-constant stream of data and communications flowing in and out of payer systems. Providers that want insight into estimated time or status of paperwork must be proactive. Data can sometimes get lost in the shuffle on the payer side, and communication isn’t always as timely as providers would prefer. Even worse, payers may require additional steps or information from a provider but will be slow to inform them.
Follow-up can be done in many different ways – portal, phone, email – and in many cases, providers may have to try several avenues to get an update. Many clearinghouses provide a service whereby they track the progress of data and payment, but some payers will only provide status to providers directly. It’s incumbent upon the provider to inquire about how things are coming along.
Delays and rejections in provider/EDI enrollment, credentialing, and other common transactions between payers and providers are preventable. While vigilance and proactive measures will help, these common pitfalls can be avoided best through automation with Madaket. Available to clearinghouses and third parties, the Madaket platform accelerates EDI enrollment and credentialing processes by keeping an updated form library, providing enrollment status from payers, prompting updates on information, and making data entry easier through a provider portal.