Top KPIs Healthcare Organizations Should Track to Optimize Payer Enrollment

As the industry shifts to value-based care, healthcare organizations are changing their workflows and tracking an unprecedented number of metrics to evaluate and improve performance for financial and clinical success. The same should be true for their payer enrollment processes.

Value-based care and population health management not only bring volumes of new data to an organization, but also an influx of new providers. Hospitals and practices alike are hiring more primary care and specialty providers to deliver comprehensive, team-based care for value-based success.

The role of medical staff services is becoming increasingly important in the evolving healthcare environment. The department has always performed primary source verification, credentialing, and privileging. But today it’s shouldering more responsibility for ensuring providers are enrolled in the organization’s payer networks in order to get reimbursed for the care they deliver.

Many departments, however, are struggling to handle increasing volumes of provider applications, leading to reimbursement delays and, in some cases, claim denials.

With organizations writing off 90 percent more claim denials, monitoring and improving payer enrollment performance is critical to boosting the bottom line and succeeding in a new value-based world.

Key performance indicators (KPIs) can help hospitals and practices track payer enrollment performance, identify processes putting revenue and timely care delivery at risk, and improve workflows to streamline credentialing and enrollment.

To improve payer enrollment, healthcare organizations should be tracking the following KPIs to successfully shift into value-based care while remaining financially healthy.

Days in enrollment

Tracking the number of days payers take to respond to roster and single application submissions is a staple KPI for medical staff services. Understanding how long payers need, on average, to process a provider’s enrollment application indicates how early an organization should be submitting applications to ensure their providers can deliver reimbursable care by their official start date.

Healthcare organizations should be tracking the day an application is summitted to a payer, each time a follow-up is made, and when a payer issues a number to a provider or accepts the application, according to Maggie Palmer, MSA, CPCS, CPMSM, FACHE, a National Association Medical Staff Services (NAMMS) instructor.

The payer enrollment process typically takes anywhere from 90 to 120 days. Anything above 120 days indicates a significant issue with the payer or internal processes.

Pending dollars due to payer enrollment

While healthcare organizations wait on payers to approve enrollment applications for their new providers, leaders should know how much revenue is at risk, NAMSS’ Palmer adds.

Each day a provider cannot deliver care to patients could mean hundreds to thousands of dollars in lost revenue depending on the provider’s specialty and the organization’s patient volume. Some providers also receive temporary privileges while medical staff services waits on a pending application, but this flexibility could be putting revenue at risk.

Monitoring the revenue at risk during payer enrollment is a key metric to have in the back pocket. The KPI can be used to show hospital or practice leaders if an investment is needed to the improve payer enrollment process.

Number of applications denied or returned for additional documentation

Physician credentialing and payer enrollment are complex processes that are oftentimes rooted in manual workflows. Between shuffling papers and other manual procedures, errors are common and can lead to application delays and even application denials.

Tracking the number of applications payers return to healthcare organizations for additional verification, documentation, or other common errors is essential to evaluating payer enrollment performance. An uptick in that number, as well as the amount of applications denied, indicates a breakdown in payer enrollment processes.

The metrics give healthcare organizations the ability to quickly identify issues in payer enrollment and improve processes to ensure payers approve applications the first time.

Processing times

Understanding how long it takes the medical staff services department and providers to complete a payer enrollment application is critical to an organization’s success. The internal performance metric enables leaders to evaluate their staff’s performance and identify and correct workflow inefficiencies.

Healthcare organizations should evaluate the amount of time medical staff services takes to enter a provider into the organization’s credentialing and enrollment systems, as well as to other credentialing and enrollment entities, such as the Council for Affordable Quality Healthcare (CAQH) and the Medicare Provider Enrollment, Chain, and Ownership System (PECOS).

Leaders will also benefit from tracking the amount of time providers need to sign all the necessary documents in their application. Oftentimes medical staff services is not responsible for slow turnaround times, and the provider processing metric will help leaders identify ways to work with physicians to complete applications in a timely fashion.

KPIs are a key tool for medical staff services and practice administrators. The metrics paint the payer enrollment picture at an organization, which allows leaders to pinpoint areas at risk and areas of opportunity.

Technology and third-party companies can help healthcare organizations start tracking and acting on payer enrollment KPIs. Whether through an IT system or a payer enrollment outsourcing service, medical staff services and practice administrators can collect data, track performance, and glean insights from the metrics to help organizations manage payer enrollment in an evolving healthcare industry.