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12 proven techniques for Medicare & Medicaid credentialing victory

For too many credentialing departments, everyday tasks are harder than they need to be. Teams are overloaded with manual work, and frustrated by the number of steps it takes to do things like onboard providers, submit applications for enrollment and create reports. 

And, government payers, Medicare and Medicaid, have some tough and significant barriers that make the credentialing and enrollment process challenging.

Understanding the complex Medicare and Medicaid landscape

Medicare and Medicaid require a much deeper level of scrutiny and detailed documentation which is essential to reduce the risk of fraud. It also makes working with these payers difficult because:

The rules keep changing. It’s tough keeping up, especially with limited staff. Each payer has unique rules. 

While these challenges are real, they’re also opportunities to improve your processes and ensure compliance.

Doing so, can lead to growth and success for your organization.

How that impacts healthcare organizations' strategies

It's pretty important to get a handle on where things stand now and what you might be up against as we head into next year.

Let’s look at a few stats that put things into perspective:

  • 54% of medical practices reported an increase in denials related to provider credentialing in 2021.
  • The challenges of Medicaid and Medicare credentialing include the complexities of eligibility and key structural differences between the government payers.
  • An anticipated 8.6% decline in Medicaid enrollment and a 17.2% increase in state Medicaid spending in 2024 signal significant shifts in patient demographics and reimbursement policies.

We know practices and provider groups feel this strain, and it's understandable.

But here's the good news: 

There are ways to smooth out this process and create success. 

12 proven techniques for Medicare & Medicaid credentialing victory

Tip #1: Get surrogacy which lead to faster enrollments

Medicare and Medicaid are fraught with long application timelines, rejections due to incorrect data or delays because of clerical errors. 

All of this can set you back by months.

We've all been there. 

Our first tip is about simplifying this. It’s known as “getting surrogacy.” It’s where you delegate parts of the credentialing process to a specialized entity.

Here at Medallion, we take on surrogacy for PECOS and payer domain access for state Medicaid applications. 

We complete applications and we let our clients review them for accuracy. Getting surrogacy creates a partnership that smooths out the bumps. 

It is something that can move the needle for you right out of the gate.

Tip #2 Pair up for regulatory agility

Pay attention to the details in your applications. It sounds obvious, but it's essential. The CMS landscape is constantly changing: 

They're adding new rules, like a pause option for non-compliance. 

They’re adding in rules for clearer terms. 

And, they want faster updates on location changes to keep provider directories updated.

Now, as things evolve, it's easy to miss a small detail. But that has big implications. 

Missing details can mean getting kicked out of a payer network. Or even facing fines. 

And the catch is, you often don't realize there's a problem until your application is denied - and that could be 30 plus days from submission, which is a lot of wasted time. 

So, keep a sharp eye on every part of your application. Take a moment and look to see if you’re in the right section. 

Make sure you fully understand each requirement. 

And keep all your supporting documents ready. 

And here's where a partner like Medallion comes in handy. Our approach is pretty unique. We can handle both individual and group enrollments together in one go.

This means less paperwork for you and more time saved.

Tip #3 - Track every step of your workflow — in one place

A tip that's often overlooked but super important: Track every single part of your enrollment workflow. 

Yes, even the tiny steps that seem insignificant.

A great way to tackle this is by building or using some type of dashboard.

Something that shows you everything, from start to finish. 

A dashboard where you can see where each request is, at any moment. 

Because, it comes down to having a way to provide clear, consistent updates for your team.

This way you can make sure everyone's on the same page.

And when payers ask for more information, you have the ability to let your providers know right away.

A dashboard also helps you document why a provider's application was declined. 

And keep an eye on closed panels.

Tip #4 - Keep detailed records to avoid payment claim issues

It’s simple but crucial. 

Keep every single document you submit to the payer. This includes your application, the confirmation of submission, and all supporting documents. 

Because if there happens to be an error on the payer’s end, these documents are your proof. They’re your way to set things right.

Also, make quality checks a regular thing in your operations process. 

This helps streamline the application submission process because you get a fresh pair of eyes to look over everything for mistakes. 

And don’t forget about training. Regular sessions with your team to go over audit results and updates in payer policies are key. 

This might feel like extra work, but they keep everyone sharp and up-to-date, preventing errors that could lead to more delays.

Here’s where Medallion steps in. You can think of us as your central hub for all things enrollment. 

Our dashboard helps confirm which enrollments your providers are PAR with. We also have an API you can utilize to integrate with other systems that are key to your internal workflows.

Tip #5 - Be compliant with CMS criteria

Stay CMS compliant. 

It's pretty self explanatory, but so essential. As mentioned with training, keeping up with payer policies matters. CMS compliance is at the top of that list.

CMS sets the rules and guidelines. Everyone else, like Medicaid and commercial payers, follow. 

While there's some variation among payers, CMS guidelines are paramount. 

So it’s really important to review the criteria frequently. This way you can catch any changes in policy, documentation requirements form updates – all of that – as soon as they happen.

Staying on top of CMS compliance also means your applications are more likely to be processed smoothly the first time around. 

Remember, it's all about being proactive, not reactive. 

So, keep those CMS guidelines close, and you'll be setting yourself up for success right from the start.

Tip #6 - Leverage the right technology for efficiency

We all know Medicare and Medicaid are notorious for being low-tech, but that doesn’t mean you have to be. 

Data is always going to be your most important asset as you are completing back office functions.

If you’ve ever wondered why some of your enrollments are stuck in limbo. Or, why some providers are having trouble getting through. 

This is where smart technology use comes into play.

Look to a solution that integrates with other systems you use for payments, referrals, or anything else. 

This makes a world of difference in helping you create smooth and efficient workflows. 

Tip #7- Mitigate provider data privacy concerns

Tip number seven is pretty timely, especially with the rise of telehealth. It's all about provider privacy. 

And it's a valid concern. 

During payer enrollment, you're handling sensitive personal information and data. That's a big responsibility.

We recommend that you make sure your software is SOC-II compliant. This way you can reassure your providers and guarantee that you're treating their data with the highest level of care and security.

In today's world, where data breaches are way too common, being able to say, 'Hey, we've got this. Your info is safe with us,' is huge. It builds trust. And in healthcare, trust is everything. 

So, make sure to not overlook this – safeguarding provider privacy is a must, and SOC-II compliance is your way to do it right.

Tip #8 - Be diligent with revalidations

Stay on top of your revalidation process. 

Trust us, revalidations aren’t just another item on your to-do list; they're absolutely essential.

Missing a revalidation date with government payers is a scenario you want to avoid at all costs. 

Because if you do, it means starting from square one again. That's a lot of time, money and effort down the drain. 

So, it's crucial to have either your internal team or your vendor partner, whoever's handling it, to keep a sharp eye on those revalidation dates.

This kind of proactive approach can save you a ton of hassle and keep everything running smoothly.

Tip #9 - Get frequent and direct communication

Reach out to the payers directly.

Sometimes, the best way to get clear info is to go straight to the source. 

In some cases, you can develop a rapport with a payer representative. 

This is great because instead of sifting through confusing website info, you can have a real conversation with a real person. 

And here's something you might not expect – many payers don’t have a large team of reps, which is actually a plus for you.

It means you have an opportunity to establish a solid, collaborative relationship.

But remember, every call you make is important. Always jot down the name of the rep you speak to and the call reference number. 

Again, documentation is key. It's your proof, your record, and it can be helpful if you need to dispute an error on the payer’s end.

So, don't hesitate to pick up the phone. Those direct conversations can be a real lifesaver.

Tip #10 - Navigate around portal inaccessibility

When it comes to Medicare and Medicaid, one of the toughest nuts to crack is getting into their portals. 

Remember our first tip about surrogacy and domain access? 

This is where it really comes into play. By securing this access, your specialists can dive into a provider or group’s application directly.

This means not having to rely on password sharing. Or having to provide authorization codes which get directed to a website administrator and run the risk of timing out quickly. 

Not having this kind of access can really slow your applications — by months.

It’s also really important to know that different states have different rules for backdating effective dates. For example, North Carolina allows a 365 day backdating period. Texas doesn’t even allow it. 

All of this goes to say that if you miss a deadline, you could be leaving money on the table - thousands of dollars potentially lost due to delays.

So, prioritize getting that portal access. It’s a step that can save you a ton of time and money, and it’s absolutely worth the effort.

Tip #11 - Swim through payer mix complexities

This process comes with a lot of dependencies. 

You've got supporting documents, differences between individual provider and group enrollments – a whole web of details.

Here's where Medallion steps up. We've codified a lot of this process for you. You don't need to worry over designing complex workflows. 

Our system tailors the required information based on the provider's profession and flags the necessary documents for each payer. It's about customizing to meet your needs.

And there’s more. We also automate how we map out enrollment dependencies. 

For example, if a Medicaid enrollment hinges on Medicare, we've got you covered. 

We can line up your tasks in the most efficient order.

Tip #12  - Be open to change

Our final piece of advice before the Q&A: Be open to change.

Understanding Medicare and Medicaid enrollments is a journey. It takes years to really get the hang of all the nuances. 

Change is hard – you’ve got a set way of doing things and you don’t want anything to break. But at the end of day, you need to think about what’s best for your providers and your organization.

Medallion: Truly unified credentialing and enrollment software

Think of software and strategic partners as extensions of your team. They can adapt to your processes, helping you become more efficient, more strategic.

At Medallion, we’re always on top of Medicare and Medicaid policy changes. We handle complex cases, from telemedicine to traditional setups. 

We want to take the paperwork load off your shoulders, so you can focus more on patient care. 

That's what it's all about – working smarter, not harder, and making a real difference where it counts.

Get in touch to see how you can benefit from Medallion’s platform and reach credentialing and enrollment success.