In every profession, myths and fallacies based on misinformation or apprehension persist year after year, until they become urban legend. Perhaps there was a kernel of truth in there somewhere, at the start. But like in the kids’ game telephone, distortion takes over, the source long blurred and unknown, and the fiction lives on.

Let us take a moment to ID and debunk some urban myths of credentialing and payer/provider enrollment, shall we?

7. If a payer says “no” to a provider, there’s nothing you can do…the tribe has spoken.

Au contraire! There are numerous ways to try getting past a payer’s “no,” when you’re trying to enroll a provider into an insurance plan. You can appeal (and second-level appeal), offer additional key info to fill payer panel needs, negotiate, offer an initial trial, and take other creative paths. It may not happen overnight, but persistence often pays. Learn more here.

6. Credentialing/Med Staff is not a part of the revenue cycle.

Times they are a-changin’. The healthcare revenue cycle used to refer to claims-processing and payment collection. Now the term captures the full picture including providers’ and the medical staff/payer enrollment administration’s contributions to revenue. Both the Healthcare Financial Management Association and the Healthcare Information and Management Systems Society define it as administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue. That includes PSV, credentialing/privileging, and enrollment, which all start the path leading to profit.

5. Practices can’t survive unless they enroll providers with payers.

In reality, patients—not insurance companies—are becoming the payers because they now have many platforms to choose from (urgent care, telemedicine, drugstore clinics, etc.), don’t care to have a PCP, and/or are cutting out the “middle man” of insurance companies to receive care. Call it convenience care, direct to consumer, whatever. A growing movement of pediatricians, family-medicine physicians, and internists are opting for a different model where the doctor’s office charges a monthly fee and doesn’t take insurance. High-deductible health plans/high out-of-pocket costs are causing private practices to offer their patients this new format.

4. The most efficient order is: hire provider/set start date, credential/privilege them, enroll with payers.

Actually, if this is the order your practice or hospital uses, you might be:

  • Leaving reimbursement money on the table
  • Inconveniencing the provider or patients
  • Putting the control in the payer’s hands
  • Doing double time on some cred/PSV steps

Check out #3 in this article.

3. CVOs are for primary source verification, and their use makes you more likely to be scrutinized by accreditors.

No on both accounts. If you use a CVO, you won’t be painting a target on your back for accreditors. And you’re in great company. CVOs have reached near saturation, meaning most health systems have an internal one or use an external/commercial CVO. NCQA certifies about 200 of them. And CVOs offer both hospital and managed care credentialing, are paperless, and do everything from application management, verification, and expirables management to recruiting, enrollment, privileging, and FPPE/OPPE. Learn more here.

2. You must turn over your P&Ps to your Joint Commission, DNV, CMS, or other surveyor when they ask.

Negative. There is no requirement that you give surveyors copies of your policies and procedures to take away, either electronically or hard copy. They may ask, and often do so, when they find policies or other material they especially like. However, it’s your call about giving that away. There is no advantage for you to let them take it. This blog offers more day-of-survey tips.

1. If a surveyor cites you on something, you can’t do anything about it until you receive the results post-survey, then appeal.

Wait a second. I’m mean, don’t wait! Your surveyor may not share this tidbit, but while they’re still onsite and there’s been an area of potential non-compliance identified, you can try to nip in the bud. If you believe they’re making a mistake, ask for a call with the surveyor and their “mother ship” asap—and specifically with the “Standards Interpretation Group.” This occurs during what’s called special issue resolution. Have the regulatory/accreditation language in question out and ready, have your P&Ps/bylaws language ready, and invite along any big guns needed on your side (e.g., physician leader, Quality VP, etc.) to state your case. This can be set up on a speaker phone so all can hear.