How do you score success?
One way we at Fifth Avenue Healthcare Services measure the effectiveness of our credentialing process is through our many credentialing audits. Our experienced credentialing team proves its credibility during each audit. The providers we service can be confident we are credentialing them according to the industry’s best standards.
In addition to our recent stellar credentialing audit, Fifth Avenue Healthcare Services earned NCQA Credentialing Accreditation, strengthening our reputation as an industry leader.
The MultiPlan Credentialing Audit
In March 2022, MultiPlan, a healthcare cost management company, performed an audit on Primoris Credentialing Network’s delegated provider enrollment policies and procedures. This audit showed that Primoris’ policies and procedures met all the requirements for credentialing, recredentialing, appeals, provider rights monitoring, and system controls.
Primoris Credentialing Network and MultiPlan enjoy a solid partnership. Primoris is the largest independent physician association in the Midwest. MultiPlan is featured among the delegated contracted companies comprising the comprehensive list of Primoris’ 54+ health plan and network provider enrollment options. Partnering with MultiPlan can prove advantageous during the provider enrollment process.
The MultiPlan Advantage
For decades, MultiPlan’s clients have saved $19 billion each year. MultiPlan’s innovative healthcare cost management solutions promise clients equality, efficiency, and affordability. These features have created a strong legacy of provider relationships.
MultiPlan works alongside healthcare payors to create cost-effective solutions. The company’s impressive history of contracting with healthcare providers allows it to offer amenable provider networks to commercial, government, property, and casualty payors.
MultiPlan’s clients enjoy the following:
- Accessing a variety of payors.
- Improving their cash flow.
- Lowering collection expenses.
- Offering contracted network reimbursement and punctual payment opportunities.
- Reducing patients’ out-of-pocket costs.
- Reducing the risk of patient migration due to network coverage issues.
Providers who enroll in MultiPlan use a robust web portal to:
- Access client lists.
- Add providers to a group.
- Confirm provider network participation.
- Modify demographic information.
- Obtain and send group rosters.
- Seek contracts, fee schedules, and rosters.
- Submit billing and network questions.
- Track applications and request statuses.
Providers who need assistance with the web portal can sign up for training. They can also download handbooks that provide information concerning credentialing, reimbursement, dispute resolution, and more.
Providers who still need help can access the FAQ on MultiPlan’s website with clear answers about:
The Ultimate Advantage: Delegated Contracts
Each health plan has its application process. Applications vary by state, health plan, network, and area of practice. Applying to each one takes time to figure out each one’s instructions. Plus, filling out numerous applications is a time-consuming job in itself.
Delegated contracts result in faster provider health plan enrollment, which means providers can start billing sooner rather than later. Delegated contracts allow Primoris to use one application to add a provider to multiple plans and networks much faster than sending an application to each plan. Providers who want to apply to MultiPlan can let Primoris effortlessly perform the job so they can start billing sooner.
MultiPlan is one of Primoris’ current 54+ delegated health plan enrollment options, including:
The HealthSmart Credentialing Audit: 100% Score
In 2021, HealthSmart, one of the largest third-party administrators in the United States, completed a delegated oversight audit on Primoris’ credentialing policies and procedures. An offsite audit of credentialing files was also conducted to determine compliance. The final audit score was 100%. Like MultiPlan, HealthSmart joins the 54+ health plan and network provider enrollment options Primoris offers its providers.
The Benefits of HealthSmart
HealthSmart is the premier provider of customizable health plan solutions for self-funded employers. The company’s expertise and innovative thinking have empowered them to solve several problems in healthcare. They aim to improve health and reduce spending by offering access to the highest quality providers at the lowest cost. They can save plan dollars through their PPO networks, nationwide network partnerships, and non-network negotiations. Not to be outdone are their efforts to protect their clients by managing risk and mitigating financial vulnerabilities.
HealthSmart understands its clients. Providers have specific demands and concerns. HealthSmart can respond with first-class support that aligns with its values and mission statement. They aid companies with as many as 150,000 employees and as few as 200. The company’s ability to scale its services is one more example of its commitment to serving as many diverse consumers as possible.
Breaking Down a Perfect Credentialing Audit Score
Primoris’ perfect HealthSmart audit breaks down as follows:
- Policy and Procedure Compliance: 100% out of 100%
- Initial Credentialing Compliance: 100% out of 100%
- Recredentialing Compliance: 100% out of 100%
- Area(s) of deficiency: None
Primoris’ perfect score of 100% bolsters the company’s reputation for excellence. Serving 6,700+ providers for 20+ years, Primoris proves it can reliably supply any number of provider enrollment requests.
Primoris co-founder Brad Bond, COO, and Donna Gaydos, then Director of Data Integrity Management, led audit efforts with the Primoris team. They drew on their nearly 400 years of industry experience to achieve a remarkable victory, fulfilling the company’s mission to offer smarter, simpler, and better enrollment.
Although Primoris’ credentialing experts made it look easy, perfectly passing the audit required everyone to be at the top of their game. These audits assess how well Primoris follows payor and accreditor regulations.
Primoris must work hard to make sure the following areas are not lacking in any way:
- Adherence to certifying body standards.
- Data management technology security.
- Information handling policies and procedures.
- Roster quality.
Primoris proved it could dutifully perform in these areas.
These audits are not just for Primoris’ sake. The assessments ensure that credentialing companies do what they should to properly credential providers. Poor credentialing can see unqualified providers able to practice medicine and potentially harm patients. Improper credentialing can also hurt licensed and adept providers. These skilled physicians who are victims of lousy credentialing might be denied enrollment and employment.
Passing HealthSmart’s audit means that Primoris is a preferred provider enrollment service company in the HealthSmart network. Primoris can offer clients access to a competent Customer Service Team that can answer questions and address concerns about claims, utilization management, and more. Primoris also has access to dedicated resources like provider manuals, newsletters, search tools, and a web portal where members can get real-time member eligibility and claim status information. This online provider tool grants HealthSmart members another path to the best care available.
Another Success: NCQA Credentialing Accreditation
In addition to acing two audits, Fifth Avenue Healthcare Services and its affiliated brands, credentialing arm 5ACVO and Primoris, successfully concluded one more assessment. We earned NCQA Credentialing Accreditation.
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The NCQA (National Committee for Quality Assurance) is a private, nonprofit organization committed to improving health care quality. Founded in 1990, the NCQA has taken on the heavy responsibility of administering evidence-based standards, programs, and accreditation. The organization studies how well health plans and physicians provide scientifically recommended care to refine their standards, raising expectations of treatment.
The NCQA’s ethical models are widely known and recognized within the industry, so much so that even government clients hire the organization to measure and improve their quality of care. 173 million+ people are enrolled in NCQA-accredited health plans. 10,000+ practice sites and 50,000 clinicians have received the NCQA PCMH (Patient-Centered Medical Home) Recognition seal.
As for our NCQA success, NCQA President Margaret E. O’Kane states, “Achieving NCQA Credentialing Accreditation demonstrates that Fifth Avenue Healthcare Services has the systems, process, and personnel in place to conduct credentialing in accordance with the strictest quality standards.”
Passing the Extensive NCQA Credentialing Audit
NCQA Credentialing Accreditation evaluates credentialing organizations to ensure they follow industry-level guidelines for their contracted clients.
Fifth Avenue Healthcare Services passed the audit and was noted for its quality improvement efforts. We join an exclusive group of approximately 90 organizations that have also garnered NCQA Credentialing Accreditation.
How did we do it?
First, we had to meet the eligibility requirements. Our credentialing services had to include the following:
- Verifying healthcare provider credentials through a primary source or a contracted agent of the primary source.
- The review of provider credentials.
- The monitoring of provider sanctions and complaints between recredentialing cycles.
Second, we also had to meet the following criteria:
- We could NOT be licensed as an HMO (health maintenance organization), POS (point of service), PPO (preferred provider organization), or EPO (exclusive provider organization).
- We could NOT be eligible for NCQA Accreditation as a health plan or an MBHO (managed behavioral health organization).
- We MUST perform credentialing functions directly or via a contractual agreement.
- We MUST conduct credentialing tasks for no less than 50% of the practitioner network.
Qualifying might seem easy compared to the audit. However, the NCQA thoroughly appraised our policies and procedures.
NCQA graded us on the following:
- How information is received, stored, reviewed, and monitored.
- How promptly we verify a practitioner’s data.
- How we address discrepancies in credentialing data.
- How we delegate credentialing responsibilities.
- How we get advice from practitioners when we make credentialing decisions.
- How we identify system security control risks.
- How we present all the relevant files to the credentialing committee.
- How we restrict physical access to the credentialing information we have gathered.
- How we track edits made to credentialing data.
- How we verify sanction information.
- How well we notify practitioners about their right to review the information submitted to support their credentialing application.
- Our ability to identify and manage quality issues between formal credentialing.
- Our appeal processes.
- Our credentialing application.
- Our credentialing committee’s review process.
- Our decision-making criteria.
- Our level of confidentiality.
- Our nondiscriminatory credentialing procedures.
- Our objectivity when deciding how to deal with a practitioner who does not meet standards.
- Our policies regarding the authorization to modify information.
- Our verification sources.
- The quality of our contracted providers.
- The timeliness of the notification process regarding credentialing decisions.
- The type of practitioners we credential.
The Power of NCQA Credentialing Accreditation
Providers and practices that employ an NCQA-Accredited company like Fifth Avenue Healthcare Services can be assured that they are using one of the finest companies available. NCQA Credentialing Accreditation is a mark of excellence that promises competence and reliability. Providers can experience prompt and accurate credentialing, which can help them see patients quickly so they can begin the billing process and bring in revenue.
NCQA Credentialing Accreditation can positively affect a credentialing organization’s business. Accredited organizations can use their status when marketing their services. Clients who look for the NCQA seal are looking for the best people to work for them. An organization that demonstrates credentialing’s best practices can be considered the go-to source for the medical profession.
Accreditation also helps identify valuable contracting partners. Health plans might be more receptive to joining an NCQA-accredited company, which could increase the total number of delegated contracts. More health plan options are always a good thing.
The power of NCQA Credentialing Accreditation extends past healthcare providers and credentialing organizations. The status can protect patients from subpar care. Only qualified providers without histories of negligence can pass through stringent credentialing. The NCQA helps keep the medical industry strong from top to bottom.
More Credentialing Audits and Successes to Come
Fifth Avenue Healthcare Services will have to undergo the audit process when it is time to renew our contracts and accreditation. Health care necessitates constant monitoring. Patient safety is crucial, so the following tight regulations are essential. We are enthusiastic about credentialing and provider enrollment and will go above and beyond to pass any audits that come our way.
More information about Primoris Credentialing Network
Primoris Credentialing Network is an NCQA Credentialing Accredited company specializing in credentialing and provider enrollment, with 54+ health plan and network provider enrollment options. Primoris is a family member of Fifth Avenue Healthcare Services. Sister companies include 5ACVO (credentialing and primary source verification specialists) and Fifth Avenue Agency (MPLI and medical malpractice specialists).
Primoris initially published this article here. For more information on Primoris Credentialing Network, please visit PrimorisCredentialingNetwork.com or Contact Us.
