DENIALS !! Do you know how much they are costing you per month? Get us started with your denials, let us earn your trust. We are sure you will make us your sole vendor soon.
We prefer to use the HFMA MAP Keys
- Account Resolution
- Financial Management
- Patient Access
- Physician Financial Management
Provider Enrollment and Credentialing
Many denials can be attributed upstream to provider credentialing and enrollment. We maintain a credentialing matrix to stay abreast of the credentialing status for each payer, plan, provider. This ensures reduced denials. We leverage a few of our technology solutions to help achieve the same and can help you with 855 forms, PECOS, CAQH.
Pre-certification (Authorization) & Insurance Eligibility Verification
- We leverage our eligibility verification solutions in addition to using payer IVRs and payer CSRs to verify coverage on primary, tertiary, Medicaid etc
- In conjunction with our patient contact center team, we reach out to patients & get updated insurance information (if anything has changed since their last visit)
- Keep up-to-date/current member ID, group ID, coverage end and start dates, co-pay information etc
- As needed, we also obtain pre-authorization codes and PCP referrals as needed
- We not only stay up to date on patients’ issues with coverage or authorization but we also keep your team in the loop about the same.
Patient Demographic Entry
While insurance eligibility verifications is a crucial aspect of revenue cycle management, patient demographic entries play a big role in reducing denials downstream as well. Our team ensures that there are no issues with patient demographics with respect to name, DOB, address, phone number, medical history, guarantors (if any), insurance details etc. If any of these are missing or has been missed by your front desk, we ensure that our patient contact center team gets in touch with the patient to sort out the details. This becomes very important if we want to avoid having to rework claims.
CPT and ICD-10 Coding
Some denials are rooted in CPT -> ICD10 coding. There’s no getting around that. We work with your superbills and completed visit notes. While it is ideal if the ICD/CPT codes are noted in the same, it is not mandatory to do so. Our team is equipped to work with your superbills to ensure that work can progress with as much or as little assistance as possible. We need to ensure and prevent any up/downcoding related challenges to avoid possible future denials.
We work with your fee schedules and ensure that they are as per state/provider contracts.
Our team ensures that all patient demographics have been provided in the claim and are ready to be filed. After we do this, we ensure that we run it through a round of quality checks to ensure that our clean claims rate remains at the highest levels.
First things first – we ensure that the claims are submitted electronically. While we have met practices that do not do this, we strongly encourage our clients to submit claims electronically (we can help you with the set ups as well). Should there be an insurance requirement for paper to be used, we can do the same with the clearing house. Rejections are part of the day to day world of claims. While keeping our clean claims rates at the highest performant level, we will still see rejections for some reason or the other. This happens with everyone in this ever changing healthcare industry. We ensure that rejections are corrected and resubmitted within 24 hours.
Hopefully you are enrolled in EFT/ ERA to avoid delays in payments. If you are not, we ensure that your providers are EFT/ERA enrolled to reduce the time wasted on paper checks and payments. We post and reconcile ERA / EOB / Denials on a daily basis. We can work using your payment management system or we can also utilize our own. Either way, the net result is that your payments are posted at the earliest.
Account receivables follow up
Accounts receivables are broken down into buckets based on the age of the account. Our team analyzes the account receivable buckets and comes up with appropriate course(s) of action for each bucket. Thereafter, we prioritize our plan and work accordingly to help you slice through your A/R and recover monies due at the earliest. Typical to our communications plan, we keep you informed on a daily/weekly/monthly basis and also ensure that we have quarterly business review calls to be on the same page.
Depending on the buckets we are working on – whether they are denied, underpaid, pending / no responses etc, our team will call patients, payers, 3rd party facilities as needed to ensure we maintain the latest status of why and where the claim is “stuck”. After that, we ensure that our team takes the next corrective step to ensure that the current claim is paid for. In addition to that, we ensure that the learnings from this claim are sent to the upstream teams / processes to ensure non-recurrence of the same.
Our patient contact center team constantly monitors aged accounts, patient responses and works closely with our payment posting team to ensure that patients’ payments are posted within 24 hours. As we all know, sometimes, patients simply do not pay regardless of how many statement balances or reminders we send them. In these cases, our team evaluates whether the balance is high enough (e.g. > $50) to call and collect or not. This decision is made in conjunction with your practice and is assisted by looking at the life time value of a patient as well. Our team calls as first party collectors (on your behalf). We go above and beyond to make patients happy with the outcomes so that they pay their balances and at the same time, the relationship is still maintained for future visits.
Our surgery scheduling services team ensures that you concentrate on counseling patients and getting them ready for surgeries. Meanwhile, our outsourced surgery scheduling services team takes care of the annoying parts – ensuring that patients schedule and go for their pre-admission tests, get their medical clearances, obtaining prior authorizations for each surgery.
Frequently Asked Questions
We consider proper credentialing and contracting to be at the heart of revenue cycle management success. Of these, CAQH is one of the most important aspects to get done correctly. Once you have that piece in order, everything else flows smoothly.
Our job is to make credentialing and compliance easy. Credentialing is not rocket science but it is complex and time consuming. While credentialing cannot be automated 100% of the time, a large portion of it can. We use our credentialing software to reduce human errors, auto populate forms, inform our healthcare providers about their status, TODOS and ensure that no party misses a deadline.
How we can help with provider credentialing, CAQH, compliance
|We can help you add new providers and also if you are a start-up practice. For existing practices, when you need to add new providers or locations to health plans, we can outsource those processes for you as well.||Credentialing Services|
|CAQH Registration||As we mentioned, this labor intensive process is at the core of getting credentialing done right. Many payers now require providers to have their credentials on file with CAQH. We will maintain CAQH accounts for your providers and upload all necessary documents on a timely manner.|
|If a payer panel is open for your specialty, we will manage the process of contracting with providers. We do this with both commercial and government health plans.||Provider Enrollment|
|Medicare & Medicaid Provider Enrollment||Hopefully you are accepting Medicare and Medicaid patients. In 2020, there were around 62 million Medicare beneficiaries. Out of those, nearly 39% are enrolled in Medicare Advantage plans. We handle everything involved in setting up your practice providers with Medicare and Medicaid.|
|For most surgeons, hospital privileges are a lengthy process. It’s arduous but not difficult to do. You just have to ensure that your forms, certificates etc are in order and that you do not make mistakes nor miss deadlines. We handle this process end to end for you.||Hospital Privileges|
How does Nisos Health handle Provider Enrollment
When you want to work with patients that carry insurance, your provider(s) would need to be enrolled and “par” with the payers. Do keep in mind that your provider(s) need to be “par” with each payer whose patients they accept. In addition, they need to be “par” at the location of service. This means that if you have multiple providers and multiple locations, you need to have your providers “par” at each location where they want to service patients from a particular payer.
Provider Enrollment involves credentialing and contracting with payers. The overall structure of the process is the same, however, each payer has their own “set of rules”.
Some payers start the credentialing process with a phone call, others use standard forms and require online credentialing wherein CAQH profiles need to be updated. Just having a CAQH profile updated doesn’t really solve the problem. Your credentialing team still needs to intervene (manual process) and follow up consistently with the payers to ensure that the provider enrollment process goes smoothly, on time.
Who does Nisos Health work with
We work with the following
- Physician Assistants or Nurse Practitioners
- Physical therapy, Occupational therapy, and Speech-language pathology professionals
- Podiatrists (DPM)
- Chiropractors (DC)
- Behavioral Health Providers
What process does Nisos Health follow for provider enrollment?
We have standardized the provider enrollment process based on our experience. We use our healthcare CRM software to manage all provider enrollment processes. With each new provider group or practice client, we set up the enrollment process and details once. Thereafter, our clients can request their providers to be credentialed with any payer (if the panel is open, of course). There is no extra work needed to get this done as we handle all intake paperless.
Which payer(s) does Nisos Health work with?
- Commercial Payers
- Medicare and Medicaid (plus revalidation)
- Medicare DMEPOS enrollment (physician groups)
- CAQH Registration
We also help with NPI Registration (Type I – provider individual and Type II – business entities )
What does our team do for you and your providers?
- We assign a coordinator per client. They are your advocates with payers.
- Our staff ensures your files are kept current.
- We give you access to the same Credentialing system that our team uses. This way, you can monitor the status of your credentialing and retrieve information and files.
- We ensure that you no longer have to deal with spreadsheets or paper printouts.
- We complete all credentialing applications on your behalf.
- We submit all necessary information to your chosen payer networks.
- We maintain your CAQH profile and follow up with each payer on your behalf. This ensures that your claims do not get denied (you can use our medical billing team as well)..
- We maintain copies of all your executed contracts. This allows you to ensure continuity of coverage with payers PLUS it helps you with underpayment audit and recovery (we can do that for you as well).
Documents needed for provider credentialing
There are some documents that are needed by all payers. These are:
- Provider Licenses (you can upload this as PDF or fax to us)
- Malpractice Insurance (We will need the certificate of insurance – you can upload this as PDF or fax to us)
- DEA (federal) and state CDS certificates (you can upload this as PDF or fax to us)
- Board Certification (you can upload this as PDF or fax to us)
- Diploma – copy of highest level of education (you can upload this as PDF or fax to us)
- Latest “resume” (this needs to show the current employer)
- IRS Form W-9
- Driver’s license (has to be current)
For your business (aka – legal entity) the following documents would be needed (you can fax these to us or upload them using our CRM):
- IRS form CP 575 or replacement letter 147C. This is needed for EIN verification. IRS would have sent you this letter when you obtained an EIN from them (when you first registered your business). Medicare will NOT process your application without the 575 or the replacement 147C.
- Business Licenses.
- If you are a therapy facility, we would need a copy of your office lease as well.
- If you are enrolling in Medicare, we would need a Letter of bank account verification.
Various other documents *might* be needed based on the payer. These *might* include:
- Collaborative Agreement (required for Nurse Practitioners)
- Admitting Arrangement letter. This is required for providers who do not have hospital admitting privileges. Do keep in mind that we also help with hospital admitting privileges.
- Prescribing arrangement letter. If for some reason, your providers do NOT hold a DEA certificate.
If your provider(s) are educated outside of the USA, the following would be needed:
- ECFMG Certificate (if educated outside of The United States)
- Passport or other citizenship documents
Credentialing process timelines
Plan for a good 90-120 days, start to finish. If there are any errors or mistakes in your submission, then the timeline starts over again. While the credentialing process is not rocket science, it does require meticulous efforts to reduce errors and rejections.
First, you are going to get credentialed (i.e. the payer will verify the credentials you submitted). Then, you are going to get a contract. This contract is also going to have effective dates. This is when you actually are “par” (aka participating provider).
Keep in mind that unless you are “par”, you cannot bill the payer. Most, if not all, payers do not allow retroactive billing.
Medicare is a tiny bit faster – 60 – 90 days. However, this will vary based on the state (i.e intermediary). However, the good thing about Medicare is that they will consider the application receipt date as the effective date. This allows you to retroactively bill Medicare. Additionally, you also get a 30 day grace period from Medicare that’s above and beyond the effective date. So, you get to bill retroactively for 1 more month.
DMEPOS applications are harder to get approved on. For DMEPOS suppliers, you need to plan for some additional time for sure. Medicare scrutinizes DMEPOS applications a lot – primarily due to all the scams that had come to light of late. You are almost guaranteed to expect a site visit. Plan for a total turnaround time of 90 – 120 days. There’s nothing we can do to speed this up.
Service location requirement
You need to have a service location before you can be credentialed. There’s no 2 ways about it. You cannot use your home address. You CAN, however, list the address of an office space you’re having built out or taking over. BUT, you cannot do this more than 30 days prior to starting to see patients at that location.
Does Nisos Health help with Medicare Revalidation?
Your providers need to revalidate Medicare enrollment every 3 years. Your providers need to complete the CMS 855I paper application. Alternatively, they (or you) can use PECOS to complete the revalidation online. If you are a group practice, then you should be using the CMS 855 B application. This is a good time to set up EFT (electronic funds transfer) for your group as well.
IMPORTANT – you only have 60 days from the date the revalidation letter was sent to respond. If you delay or disregard this, your billing privileges will be terminated.
Relevant medicare forms to use
For individual providers, you can use the CMS 855 I form. This can be used whether you are a physician or a non-physician. However, supporting documents vary based on your “provider type”. Take note of these supporting documents for your particular provider(s). Sometimes, you do have to submit (new providers) the CMS 460 form as well. However, if you do not submit this form (and are called non-par provider), you can still get more reimbursement from patients at a maximum rate of 115% of Medicare rates.
If you are a group practice, you will also need to reassign your payments to the business entity. This is done using the CMS 855R form. When you enroll, you should be setting up for electronic funds transfer (EFT) using the CMS 588 form as Medicare is not going to issue you a paper check. They will ALWAYS pay using EFT (good thing).
So, effectively, plan for using the CMS 855I, CMS 460, CMS 588 forms if you are registering a new solo practice. If you are adding a new provider to your existing group practice, you are going to need the CMS 855I and CMS855R forms. If you are NOT enrolled with the state intermediary, you are going to need the CMS855R. Sometimes, you are going to need the CMS460 form as well.
What exactly does our surgery scheduling services do for you?
- Setting up PAT with the patient’s PCP
- Ensuring that the patients gets to the pre-admission test/medical clearance tests as scheduled
- Getting history and physical from the patient’s provider, pre-admission testing (PAT)
- Setting up pre-op, surgery and post op dates for the patient with your scheduling team
- Pre-cert and prior authorizations for the CPT and ICD that your surgeons have indicated in the surgery booking form
- Staying in contact with the patient through out the surgery process
- Ensuring that the patient shows up for their pre-op appointment
- No shows and cancellations are part of the surgery scheduling process. We ensure that we follow up with the patient to reappoint them
- COVID – special considerations for your surgery scheduling process. We get the patient their COVID dates, coordinate with the lab.
- Getting the COVID lab results before the surgery actually occurs