360° Patient Experience – Impact of Provider Enrollment

Tom Caswell
Director of Sales & Marketing
Synernet, Inc.

Is there a connection between the patient experience at your healthcare oragnization and provider enrollment?  Deb Carter, MS, CPMSM, CPCS, Synernet’s Manager of Provider Enrollment outlines the impact of provider enrollment on patient satisfaction and a patient’s bill.

Overview of the Patient Experience and Provider Enrollment
A patient’s experience with a healthcare provider extends far beyond the appointment with the provider. From the initial search for a provider to booking the appointment and months later to the bill presentment, patients are keeping score of how your organization rates. Over the course of a few months, patient satisfaction will be impacted by many variables far beyond the providers clinical skill. Studies have consistently shown provider satisfaction in the 80% – 95% very satisfied range while overall healthcare satisfaction can fall into the 70% – 78% range.

Four ways Provider Enrollment can impact Patient Satisfaction
Appointment Scheduling: A patient becomes frustrated trying to schedule an appointment.

  • Unable to find the providers correct phone number and office location
  • Provider not listed on the insurance company’s website.

Appointment Not Covered: A patient is confused and upset after scheduling an appointment. The provider’s office calls to notify the patient that they need to reschedule the appointment due to provider enrollment issues.

  • Insurance will not cover the visit.
  • Provider is not credentialed by the insurance company

Bill for Out-of-Network: A patient is confused and upset because he/she received a bill with out-of-network charges. The provider was never enrolled in the insurance network so the patient receives a higher than expected bill.

  • Provider should have been in-network.
  • Provider is not credentialed by the insurance company

Bill for Non-credentialed Provider : A patient received a bill for physician services due to an insurance denial of services. The patient is confused and upset because the bill from the provider shows their insurance denied the claim.

  • Should have been paid by his/her insurance.
  • Provider is not credentialed by the insurance company

What are the necessary steps healthcare organizations can follow to ensure best practices for Provider Enrollment? While not complicated, provider enrollment requires a coordinated effort from stakeholders in multiple departments to coordinate their efforts: process improvement.

Communication: For successful payment for services rendered to patients, there should be continuous communication of the billing department, claims management, physician recruitment, the medical staff office performing credentialing to grant privileges to practice, and the practice locations where the provider will be located.

  • Start dates are pivotal but should be realistic. A provider without a state license will be unable to start providing services in less than a week.
  • The average time for obtaining a medical license in Maine for example, (other than an emergency license) is 90 days but could take up to 120 days.

Review of Third Party Payer Contracts: Enrollment begins with the contract and contracts should be reviewed at least annually.

  • What services will the facility provide?
  • For which services will the insurance reimburse?
  • Will the contract allow for rosters or must enrollment be individual?
  • Are there contracts for behavioral health and what are the requirements/restrictions? What time factors are in place for enrollment and notification that the provider is enrolled so the facility can begin sending in claims?

Claims Management: Is someone reviewing claims to be sure that the correct codes are being used, the bill is capturing the correct information for the provider rendering the service (name, location of service). Denied claims, what is the reason for denial?

  • Medicare is a perfect example of the use of an enrollment denial code that doesn’t have to do with enrollment but rather how the claim was submitted. The explanation of the denial is that the provider is not enrolled correctly but this is not accurate. This error occurs when the facility bills for both the facility and professional fee.

Knowledge of Provider Enrollment: Provider enrollment is much more than form completion.  The experienced enrollment specialist should have a working knowledge of billing and claims, payer contracts, coding, practice management and marketing, insurance requirements, as well as the timing and requirements of credentialing in the medical staff office.

To learn more about the Provider Enrollment process, best practices and Synernet’s role in helping healthcare organizations achieve their goals, visit www.synernet.net or contact Deb Carter, MS, CPMSM, CPCS at dcarter@synernet.net

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