Prevent denials by catching credentialing issues

Verifying the credentials of ordering physicians should be an essential part of revenue cycle management, and it could prove to be a fruitful endeavor.

Ximena Restrepo, compliance and privacy partner for Billings Clinic–Logan Health, which serves residents of Montana and Wyoming, said Billings-Logan has saved thousands of dollars in avoided claim denials or in avoided regulatory legal action after revamping its compliance screens.

“Hospitals save money by conducting due diligence and verifying providers against federal and state exclusions, as well as verifying their medical credentials,” Restrepo said during an interview at HFMA’s Revenue Cycle Conference in March after she spoke on the subject at the conference.

AI is no help here

A lot of that work is likely still being done manually on sites that are specific to a state or overseen by CMS. And Restrepo said that it is a very common problem, and one that isn’t easily handled by technology.

“We’ve already talked to a couple of vendors, and it’s very difficult to find a system that is going to capture information from all these public databases, because they’re managed by each state,” she said. As a result, she suggests putting an FTE, or maybe more than one, on the job, because the downside can be significant.

Restrepo said a single provider found to be excluded — such as being suspended or losing their license  —  would cost the healthcare organization $100,000 per claim line for services rendered, in addition to civil monetary penalties of $24,947 per violation, and liable for a False Claims Act violation and treble damages, which is three times the governments loss.

She noted that the Department of Justice is looking at areas such as durable medical equipment, wound care, extremely expensive supplies.

“You want to make sure those orders are valid, and that the provider who referred your patient also has an active license (and) is in good standing,” Restrepo said. “And that’s kind of like the gap that I don’t think a lot of hospitals realize that that is a major risk.”

Other ways it could hurt a hospital is through payer denials resulting from providers with expired or inactive credentials — any of those services ordered and rendered by the provided will be denied for payments. Repayment obligations can result when all billing claims submitted for reimbursement by an excluded provider are mandated to be refunded to the payer if any payments were made.

And then there is potential reputational damage that results from care being provided by an unauthorized physician or nurse, Restrepo said.

How to do it

To verify a provider’s integrity and the validity of clinical orders, organizations rely on limited data, such as National Provider Identifiers (NPIs) and demographics in the written clinical order, and manually checking the public records, including state license lookups, federal/state exclusion lists and Medicare enrollment databases.

There are four basic screens that Billings Clinic – Logan Health executives run regularly, and as frequently as daily.

1. Provider profiles. Check on such sites as DocInfo.org.            

2. Exclusion check in federal and state databases. Software is available for this, or it can be performed manually at such sites as the Office of the Inspector General’s List of Excluded Individuals/Entities, known as LEIE.

3. Licensure and credentialing. Check national/state medical board databases and nursing license databases.

4. Medicare Provider, Enrollment, Chain and Ownership System enrollment/eligibility. Can check Medicare enrollment public databases.