Friday, October 28, 2016

Is Your Facility Ready for MACRA?



Yikes, another acronym! What is MACRA? It stands for Medicare Access and CHIP Re-authorization Act (MACRA) and is part of the Centers for Medicare sweeping payment reforms started in 2015. MACRA created the Quality Payment Program that rewards physicians and clinicians for giving better care, not just more care, and goes into effect in 2017.

How is MACRA different from Hospital Value-Based Purchasing?


The Hospital Value-Based Purchasing Program rewards acute care hospitals with incentive payments for the quality of care they give to people with Medicare. This program adjusts payments to hospitals under the Inpatient Prospective Payment System (IPPS) based on quality of care. MACRA is focused on improving the way physicians and clinicians are paid, to incentivize quality and value of care over quantity of services. Simply put,  HVBP focuses on the payments hospitals receive from CMS and MACRA focuses on payments physicians can receive from CMS. How does this affect you? Well if the majority of your physicians are hospital employees, then your facility must manage and account for both payment incentives in order to optimize your overall reimbursements from CMS.

Download our latest whitepaper - HOW WILL YOU RESPOND TO MACRA? Sweeping Changes to Physician Reimbursement and we will walk you through 3 ways your facility can prepare for MACRA.

#1. Educate Your Providers


It’s important that not only is your administration aware of the details surrounding MACRA, your providers should be too. Take the time to sit down with them to discuss how MACRA will affect them and how you can work together to maximize any and all reimbursements. MACRA will be implemented through a framework called the Quality Payment Program, which offers clinicians two paths for participation: The Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (APMs). Most Medicare participating physicians will initially utilize MIPS. The MIPS breakdown is shown below:

Data from HealthStream/Decision Health Whitepaper


50% of the MIPS score is based on quality. How does your organization define quality? Best practice is to get your providers involved in defining and setting the Quality goals that they will be measured on. Buy-in from both the clinical and administration teams will ensure success in meeting these new CMS payment programs.

#2. Identify and Track High-Performance Areas in Quality 


First, it's important as we discussed earlier to identify those quality measures you want to define as your high-performance areas. To help you do this CMS has outlined how they will score the Quality Performance category:

  • Each quality measure will receive a score of 1-10 points compared to an historical benchmark (if available). Zero points for a measure that is not reported
  • A bonus will be rewarded for reporting outcomes, patient experience, appropriate use of technology, patient safety and EHR reporting
  • Measures will be averaged to get a score for the category

As you can see they are looking for much of the same “quality” areas that are currently tied to the HVBP program including clinical outcomes, and patient safety.

Second, since your facility already has to comply with the Joint Commission's Ongoing and Focused Professional Practice Evaluation (OPPE and FPPE) regulations why not utilize this same reporting to track your MACRA quality measures.  A good OPPE analysis should provide a summary of how your physicians are meeting the specified clinical/patient safety outcomes with benchmarking, a measure of patience experience including CAHPS survey scores and provide a provider's social index which is an indicator of how the provider is viewed online in social media.

Example of an OPPE Analysis and a Provider Performance Profile Report

#3.  Review your Quality Resource and Use Report (QRUR)


The Quality and Resource Use Report (QRUR) shows how your payments under Medicare Part B fee-for-service (FFS) will be adjusted based on quality and cost. The report includes performance information from measures reported through the Physician Quality Reporting System (PQRS) and uses Medicare claims to calculate additional quality outcome measures and cost measures. Performance is compared to benchmarks of similar peer groups. Data in the QRUR is used by CMS to calculate your Value Based Payment Modifier (VBPM) and subsequent payment adjustments (positive, negative, or neutral).

Past QRURs can identify opportunities for improvement and also help you point to performance indicators that should be monitored and tracked with your OPPE analysis. Having your OPPE analysis and QRUR in sync can help you optimize your reimbursement payments for your providers and for the hospital as a whole.

Now that you know what MACRA is and how your facility can prepare for the changes, why not take the necessary steps to ensure your providers are in sync with the quality goals desired and that you have a good performance monitoring plan is in place. What to learn more? Click here.

Wednesday, October 26, 2016

3 Ways a Proper OPPE Analysis Can Improve Performance and Impact Your Hospital Value-Based Purchasing Reimbursements


Guest Post by Lisa Rothmuller, Director of Corporate Strategy; Echo, A HealthStream Company


Dinner with family and lunch with co-workers are the breaks from our busy schedules that we all cherish. Good food, friendly company, and great service is what we all aim for during these outings. While we can generally pick a restaurant with good food and we mostly have a say in the friendly company that we invite, it is the third factor of great service that we often leave up to chance.

We all wish for great service but there is no doubt that we have all experienced both fantastic and poor service while dining out. Both of these experiences play a role in our decision to return to a restaurant. If we experience great service, we’ll continue our patronage to that restaurant; if we experience poor service, we’ll caution our family and friends about visiting that restaurant.

While excellent service is not always on the top of the list for why to re-visit a restaurant, it is these return visits that lead to consistent revenue and growth for a restaurant. The same rings true for healthcare facilities. Most of us hope that we don’t need to visit a doctor or hospital often, but during those trying times, we would like to know we will receive the best quality of service.

With quality in mind, The Center for Medicare and Medicaid Services (CMS) launched their Hospital Value-based Purchasing (HVBP) Program in order to set performance standards and reward acute-care hospitals for the quality of care they give patients. CMS is basing the level of reimbursements on measured performance scores as they relate to the quality of care.

Download our new infographic - Value-based Purchasing and OPPE: The Quality Connection and we will walk you through 3 ways you can utilize OPPE measurements to improve your hospital’s performance and ultimately your HVBP reimbursements.


# 1. Identifying Best Practices 


Evaluating every provider is a hefty task. Especially if you work within a health system that employs thousands of health care providers. Capturing all of this data not only helps determine which of your doctors are performing well, it also allows you to track trends that may be used to create new practices within the organization. For example, if a provider, or group of providers, is consistently showing a lower ALOS than the group or national benchmark, exploring the reasoning behind this data can lead to having this practice adopted system wide as a new standard of care.

# 2. Uncovering Areas of Improvements 


While we may not like to admit it, we all have areas where we can improve and the same is true within health care organizations. The ongoing discovery of these areas needing improvement and developing improvement processes, demonstrates that your organization is dedicated to quality patient care and safety. Some of their performance measurements may be due to the need for additional training or mentoring. If a provider’s performance is showing increases in adverse outcomes, they may need additional proctoring in a certain clinical protocol to refine their skills. Having a system in place that can quickly identify these areas and put an action plan in place is crucial for success. Doing this ensures that your providers are delivering the highest quality of care. The result can have a major impact on your Clinical Care score for HVBP reimbursement.


Performance Profile Example

#3. Incorporating Patient and Caregiver Feedback


The patient’s opinion matters whether it is positive or negative. OPPE measurements capture provider’s clinical knowledge, patient care outcomes, professional skills, and areas of improvements. CMS is also looking to hold organizations accountable for patient and caregiver experience. To obtain this data, health systems need to make sure they are evaluating CAHPS scores and also using tools to evaluate online reviews for providers that can be obtained detailing how a patient felt about his or her experience and if they would recommend that provider or not. A good system can collect these performance indicators in a single dashboard for a comprehensive assessment.

Gathering and evaluating all of this data is daunting, but proper analysis and action plans can be the key to maximizing your Value-Based Purchasing reimbursements.Now you have the tools to know how to better integrate your OPPE measurements into the current CMS value-based scores. By creating best practices, continuing to make improvements in quality of care and listening to your patients you can make sure that your hospital is maximizing its monetary rewards.  Want to learn more? Click here.

Wednesday, October 19, 2016

4 Tips for Accelerating Provider Enrollment

Don’t let this happen to you…


You acquired a new 10-physician practice on January 1st. All 10 immediately began seeing patients on your behalf, and your hospital began paying these physicians their agreed-upon salaries and benefits. It is now April, and none of the physicians has yet completed the full Provider Enrollment process. The physicians have collectively generated almost $4 million in charges for which your hospital will never be reimbursed by payers, and you are facing a stunning write-off for the first half of the year.

Has a version of this scenario played out in your organization? If so, you are not alone.

For years, hospitals have considered Provider Enrollment a back-office function. It is separate from the provider credentialing process but shares many of the same characteristics - it is complicated, redundant, and time-consuming. The enrollment process may cause frustration to providers and administrative staff alike, but it is not traditionally considered a strategic function worthy of attention or added resources. However, a series of new industry developments has greatly escalated the importance of the enrollment process. Unfortunately, many healthcare leaders are only realizing this as they incur significant and surprising revenue losses, and the result is that hospital leaders are now scrambling for better solutions to this new administrative nightmare.

Our research shows that a high percentage of those who manage the Provider Enrollment function are struggling with the effectiveness and efficiency of their current process. Their top priority in this area is to reduce the time it takes to enroll providers. Download our new infographic - The Inefficiency of Manual Provider Enrollment Application Processes, and we will walk you through 4 ways your organization can accelerate your provider enrollment process.

#1.  Automate Your Application Forms


One way to speed up the process during the initial provider enrollment is to make sure that your enrollment applications can be automated with pre-formatted payer forms. Every payer has their own unique set of data required to enroll a provider. The more of this information that can be pre-populated when filling out the initial application the quicker the application can be submitted. An added bonus would be to have your enrollment process integrated with your credentialing process so that all of your individual provider information can also be uploaded to the enrollment application forms.

#2.  Integrate with PECOS 



What is PECOS? PECOS (Provider Enrollment, Chain and Ownership System) is an electronic portal sponsored by the Center for Medicare and Medicaid Services that supports the Medicare Provider and Supplier enrollment process by allowing registered users to securely and electronically submit and manage Medicare enrollment information. The PECOS submission can be automated with software functionally that allows for direct data exchange between your system and the PECOS electronic portal. A direct exchange will ensure data accuracy and faster billing.


#3. Integrate with CAQH


What is CAQH? CAQH (Council for Affordable Quality Health Care) is a non-profit alliance of health plans and trade associations, developing and leading initiatives that positively impact the business of They host a universal credentialing database for health care providers.

How does it work? A provider requests participation in a network that accepts the CAQH application. The health plan initiates an online account for the provider. The online application is completed and submitted to CAQH along with several other supporting documents.  Once the application is complete, any insurance company that accepts the CAQH application can access the provider’s information, expediting the enrollment process.  The provider information typically needs to be updated every 120 days.

Many health insurance plans today are signing on with CAQH. Having the ability to directly integrate with their database to submit and update provider data allows you access to multiple plans at once, submit ONE application, saving you time and significantly increasing the efficiency of your enrollment process.


#4. Automate Common Payer Transactions such as EDI, EFT, and ERA



The average healthcare provider works with 25 payers. That means a lot of paperwork just to get paid. As we discussed earlier, each payer requires a unique set of forms, procedures, and data to be submitted in order to enroll for Electronic Funds Transfer (EFT), Electronic Remittance Advice (ERA), Electronic Data Interchange for Claims (EDI) and other common provider-payer transactions. When providers make minor changes to their enrollment information, they must submit these forms again.

Traditionally, time is wasted dealing with paper forms, correcting manual errors, and tracking down the status of enrollments. By Streamlining your process with an automated payer transaction system, providers can fill out a simple online form once and the enrollment data is delivered to all payers from an online list with a single click. The result? Less paperwork, faster payment.

Now you have the tools to know how to significantly accelerate your provider enrollment. By standardizing on paperless best practices, you can make your provider enrollment process less time consuming, maximize resources, and better control your revenue cycle. What to learn more? Click here.



Wednesday, October 12, 2016

5 Things to Accelerate Your Credentialing Process


Please raise your hand if you feel like your credentialing process is a bit like applying for a new home loan!

When you start the home loan process you are hit with filling out a lengthy application with all your personal information since birth, having to verify your employment history, outstanding debts, provide copies of your bank statements, past tax filings, obtain a credit report, give a blood sample (not, but it feels that way) and more, killing any excitement you had about your potential new home. As a new home buyer its daunting enough to have to gather all this information – never mind knowing that your loan can take upwards of 45 days to process regardless of your good history and credit score, and you could be denied by an underwriter.

Well there is good news! Physician credentialing doesn’t have to be as daunting as the home loan process. With the right tools at your disposal you can quickly and easily finalize all the required data and approvals all without delays. Download our free Paperless Credentialing Solution Toolkit, to discover opportunities to expedite provider credentialing while we will walk you through 5 things to avoid. Here we go.

#1. Hard Copy Applications


Different from applying for a home loan, credentialing applications should be done online, not on paper. An online application will accelerate your operations, ensure accuracy and completeness, reduce errors, and requests for missing information. Eliminate time-consuming data entry with a secure portal to collect provider information, the ability to download the information directly to your database and automated data checks to assure complete and accurate data. An online application process will reduce the time it takes to get back applications during your biannual re-credentialing. Speaking of re-credentialing, the ability to pre-populate online applications with current provider data will improve response time and increase provider satisfaction.

#2. Inefficient Provider and Interdepartmental Communications


Another area that can delay the credentialing process is communicating with providers as to what their tasks are and how to complete them. One way to avoid delays in communication and time to complete tasks is to utilize a provider portal. A provider portal is a one-stop dashboard for a provider to view and act upon their multiple tasks through a smart phone, tablet or laptop. A portal enables providers to quickly view and manage all their information.

Full onboarding of providers includes interactions with different departments, not just credentialing. HR, IT, Marketing, Clinical, Scheduling and others all have tasks that are associated with getting the provider up and running and seeing patients. Being able to centralize communication with all of these departments will make the onboarding process more efficient. Facilitating interdepartmental communications with a system whereby each department can view workflows and quickly manage their respective onboarding steps will accelerate the enire onboarding process.

#3. Manually Verifying Data from Primary Data Sources



There are many credentialing data sources that need to be verified including licensing, state boards, NPDB, DEA, provider affiliations and more. Contacting each of these sources manually even with an email can be a slow process, especially waiting for a response. Why not access these sites automatically, query each site for the desired information and have the results returned to you almost immediately? Not only do you have to verify licensing and certifications, but you also have to check for sanctions, exclusions and disciplinary actions on your providers. Integrating with all of these sites automatically will prevent major delays in data acquisition and significantly decrease your credentialing completion time.


#4. Manually Tracking Privileging and Peer Review Activities


Are your department chairs review a manila folder full of credentialing papers? How much time does this take and how fast can they get this done with their busy schedules? What if you had an automated process to electronically assess the provider, review the initial and re-credentialing provider data, grant or comment on clinical privileges, and take immediate action on the file. How much time would that save?

Just like with provider assessment, peer review can be a lengthy process if one is required to physically write a report on every case. Why not provide a customizable form to track performance indicators? Online tracking mechanisms provide timely and more effective closure to open reviews, improve patient safety through the automatic generation of reviews, eliminate manual form errors by allowing for required fields, provide selection criteria and improve communication among participants of the peer review process, reviewers and the Quality Department.

#5. Not Proactively Tracking and Monitoring Appropriate Performance Measures


The Joint Commission requires hospitals to set OPPE standards. The value of OPPE depends on the measures selected by the medical staff, how well those measures represent activities that reflect the quality of care and performance, and how effectively the resulting information is used. Utilizing an online dashboard where all main performance indicators can be viewed is key to having visibility to the level of performance of your staff. Such a dashboard can be used to automatically track patient data such as admissions, mortality, and average length of stay, which can be used to address delivery of optimal care, and safeguard ongoing reimbursements. Collected data can be utilized to measure your practitioners against industry standards on the national, state and enterprise levels. Organizations that provide ongoing computerized access to data have found that practitioners will look at their own data and proactively implement changes to their practices especially when they are shown data that they are not performing to the same level as their peers.

Now you have the tools to know how to significantly speed up your credentialing process. By standardizing on paperless best practices, you can make your credentialing process less daunting, minimize delays, shorten your credentialing time and provide more value to your organization. What to learn more? Click here.

Monday, October 3, 2016

Where Is Provider Credentialing Headed?


An Interview with credentialing expert Meg Terry, Senior Vice President, Corporate Strategy at Echo,     

A HealthStream Company 







Article was first Published in Provider Advisor Magazine, Q4 2015

How do you see Physician Credentialing changing over the next 2-3 years?


I think we will continue to see an increased emphasis on reviewing and assessing clinical competency when making initial credentialing, re-credentialing, and privileging decisions. Clinical privileging will rely on evidence-based methodologies to demonstrate that the provider has received the appropriate education and training to diagnose and treat their patients.

Another area is the expansion and integration of new data sources, including national data such as the CMS open payments database and the Physician Quality Reporting System (PQRS). Particularly with PQRS tying reimbursement to quality measures,there will be a renewed emphasis to assess thequality of care being provided.

Finally, as hospitals and medical groups are being acquired and merged, the CVO (Centralized Verification/Credentialing Office) will continue to play an important role in streamlining credentialing for health systems, including those that cross state lines. Echo’s suite of solutions provide methodologies to automate and consolidate many of these processes so the medical staff services professionals and physician leadership can focus on the data rather than on the data collection process.

Currently, various aspects of physician onboarding (including credentialing) are being handled in multiple areas of a hospital or health system. What are some of these processes that could be consolidated under the umbrella of “physician onboarding?”


The provider onboarding process, which usually takes 90-180 days, includes several departments within a hospital or health system, including Human Resources, Credentialing Provider Enrollment/Contracting, IT, Compliance, Safety, Marketing, and more. With accelerating provider employment, there is a corresponding increase in the number of providers who need to be quickly brought onboard so they can begin seeing patients as quickly as possible, and can generate paid invoices as quickly as possible. Our solution enables a shortened revenue cycle.

At Echo, we look to automate each onboarding activity with onboarding workflows that include online credentialing applications, status portals, hands-free primary source verification, online credentials file review, and provider application generation for the various payer plans and networks. We’re also developing new tools to provide an easy method to quickly identify where providers are within the onboarding process to eliminate roadblocks and communicate with all stakeholders.

Can you share any specific customer experiences or outcome improvements when they adopt Echo?

Echo serves as the Master Provider Database, or a single source of truth, for many hospitals and health systems. Our clients are exchanging data with their legacy systems on a daily basis, eliminating redundancy and duplication. One client updates over 100 different provider databases in their health system each night!

In addition, several of our clients have moved to a paperless credentialing process. It’s like an Electronic Health Record (EHR) for provider data. By having an electronic record, other departments within the hospital can immediately access clinical privileges,licenses, photos, demographics, and other key provider data elements.

What have you learned from customers recently?


I’ve learned how forward-thinking clients are measuring clinical improvement using provider scorecards. To support objective and continuous privileging, the Joint Commission in 2007 began requiring Focused and Ongoing Professional Practice Evaluation (FPPE and OPPE). EchoAnalytics functionality provides the automation to acquire data from multiple sources, produce comparative data, and capture several different quality metrics.


About Meg

With nearly 30 years of experience in Provider Credentialing Automation, Meg Terry specializes in
empowering healthcare organizations to increase efficiency and reduce costs by streamlining processes, implementing automation strategies, and ensuring the integrity of provider data. Meg is Senior Vice President, Corporate Strategy at Echo, A HealthStream Company. She joined the organization (previously HealthLine Systems) in 1987 and is recognized as the guiding force behind the development of the company’s industry-leading medical staff management software systems. 

PUT DOWN THAT PEN! It’s Time to Go Digital with Provider Enrollment

Excerpt from an Interview With Lance Herbert, Vice President of Payer Credentialing & Provider Enrollment for Echo, A HealthStream Company


This article first appeared in Provider Advisor Magazine, Q1 2016

Why is provider enrollment getting so much more attention?


As the trend to employ providers continues, enrollment is now a top revenue cycle priority for healthcare organizations. In our recent white paper entitled PROVIDER ENROLLMENT: An Emerging Revenue Cycle Imperative for Hospitals, we stated that in 2014, for the first time, more than half of all U.S. physicians are employed. This represents almost a 75% increase in the number of employed physicians since 2000. As healthcare organizations hire providers, they must enroll the providers with payers; there is also an increasing expectation to shorten the onboarding times. Proper and efficient provider enrollment is the key to providers’ participation with insurance plans. The quicker provider enrollment is completed, the quicker healthcare organizations can be reimbursed for their providers’ services, which also results in the reduction of at-risk receivables.

High profile failures due to improper provider enrollment are catching the attention of healthcare organizations. In one prominent example, the State University of New York (SUNY) was forced to shut down Long Island College Hospital (LICH) after losing over $100 million. SUNY treated thousands of patients at LICH for free for almost two years due to failure to file the proper enrollment paperwork with insurance companies. While this may be an extreme example, it clearly points out the importance of proper provider enrollment and the severe financial implications that can result by ignoring it.

What are some of the provider enrollment challenges you are seeing among customers?


Our customers want to be able to leverage their resources, including their data. While data capture and information management is more of a necessity today, some customers wish to go a step further and analyze their statistics against benchmarks. This is an area that is generally lacking in the provider enrollment space, so we are investing in development of new tools that will help our customers overcome these challenges.

Nearly every customer wants to reduce the time frame required to enroll their providers. They realize that they can increase revenues by completing the enrollment process before their providers start seeing patients, which results in faster and potentially larger reimbursements. One key factor behind operating shortfalls at healthcare organizations that are adding employed providers is the unfamiliarity of hospital employees with the complexities of the provider enrollment process. Hospitals are finding that they are soon overwhelmed by the credentialing burdens they have assumed. It is critical for these organizations to identify solutions to help them manage these challenging tasks.

What are the functional changes you advise customers to make in terms of their provider enrollment processes?


For medical practices, the first change is to identify, define, and utilize a single, centralized location for provider data. Most of our customers have myriad data sources before they implement our software. This may include paper, spreadsheets, several databases, homegrown systems, filing cabinets, electronic files on multiple computers, and more. Using our system as the source of truth allows everyone in the organization to know exactly where their critical information resides and offers them quick and easy access to it.

For hospitals, we suggest integration of the credentialing, privileging, and provider enrollment process, platforms, and/or teams. We recently conducted a 2015 Provider Enrollment Survey of 130 hospital and health system credentialing executives across the U.S., and respondents strongly supported this change—89% of them stated that this integration was either somewhat or very important to their initiatives. Driving this desire to integrate is an increasing number of mergers and acquisitions, as hospitals are joining systems at an unprecedented rate, fueled largely by pressures from the Affordable Care Act and the pay-for-performance penalties of CMS regulation. A key driver of these consolidations has been the hope of increased efficiencies as economies of scale are achieved and processes are standardized throughout the enterprise. It now makes more sense than ever before to extend this standardization to the realm of provider credentialing, privileging, and enrollment.

What should we expect for the future of provider enrollment?


Provider enrollment has long been overrun by paper. Even in today’s digital world, credentialing departments are often filled with stacks of paper applications that must be completed, signed with wet ink, and mailed to payers. The future of provider enrollment will look different. The next phase, which has been in transition for the past several years, includes online applications in lieu of paper applications. This is becoming increasingly common, particularly with Medicaid enrollments. Following online applications, I anticipate we will begin to see EDI (electronic data interchange) between healthcare organizations and payers, including Medicare. Those who aren’t preparing for it will be left behind. We also expect organizations to begin using predictive analytics, allowing them to address issues before they occur rather than being forced to react to problems.

Another opportunity for bringing efficiency to the provider enrollment process is in the area of delegated credentialing, which is when hospitals or health systems take over the enrollment function on behalf of their health plan partners. In our 2015 Provider Enrollment Survey, over 80% of respondents indicated that delegated credentialing was either a somewhat or very
important initiative to their organization. We see this as a trend that is continuing to gain steam.

About Lance


Lance is Echo’s Vice President, Payer Credentialing & Provider Enrollment. He is the product owner of EchoOneApp, the company’s core provider enrollment solution, and he operates as the general manager for Echo’s office in Brentwood, Tennessee. Prior to this role, Lance joined SyMed Development, a HealthStream company in 2000, where he served in multiple leadership roles, most recently as Vice President, Sales & Marketing, during which time he significantly expanded market penetration and drove additional revenue growth while implementing methods to improve product installation, application testing, and upgrade distribution.