Tailored Third Party Administration

Provider Enrollment, Chain, and Ownership System: Streamlining a Federal Limited Benefit Health Plan’s Provider Enrollment Process

Karna implemented an provider enrollment process improvement that saves time and improved accuracy for a Federal limited benefit health plan.

CHALLENGE
Solution
RESULTS

Challenge

Provider enrollments can be time-consuming and filled with errors due to manual data entry. 

Karna supports a federally established limited benefit health plan that administers medical and pharmacy benefits to eligible program participants. The Program is consistently looking for innovative ways to help improve and streamline the provider enrollment process. The challenge we faced was that the Program needed to identify a provider enrollment solution that did not depend on the negotiation of proprietary provider contracts while also ensuring reliable provider credentialing. Prior to June 1, 2020, the negotiation process was time-consuming, and the Provider Services Team had to subsequently load the providers into the claims system either manually or through an autoload process. This too was time-consuming and required manual data analysis and data entry of the information into the claims processing system.  

Solution

An end-to-end solution

On June 1, 2020, the Program implemented a solution using data from the Provider Enrollment, Chain, and Ownership System (PECOS), streamlining the provider enrollment process from end to end. PECOS is an online Medicare enrollment management system that allows a provider to enroll as a Medicare provider or supplier, review and update needed information, and report changes to their enrollment record. To enroll through the new solution, providers must be enrolled in Medicare. Providers and other authorized users access the Program’s Provider Enrollment System via a website interface that enables them to begin a new enrollment request or check on the status of an existing enrollment request. The primary benefit of the tool is that it enables us to register a provider that is fully credentialed by Medicare, and to have that record fully loaded into the Program’s claims processing system within a day of their registration. It also eliminates the need for a time-consuming credentialing exercise by leveraging Medicare’s process. The provider enrollment tool ensures a fully credentialed provider is added to the Program’s provider network in a much more streamlined and expedient way.

Solution

An end-to-end solution

On June 1, 2020, the Program implemented a solution using data from the Provider Enrollment, Chain, and Ownership System (PECOS), streamlining the provider enrollment process from end to end. PECOS is an online Medicare enrollment management system that allows a provider to enroll as a Medicare provider or supplier, review and update needed information, and report changes to their enrollment record. To enroll through the new solution, providers must be enrolled in Medicare. Providers and other authorized users access the Program’s Provider Enrollment System via a website interface that enables them to begin a new enrollment request or check on the status of an existing enrollment request. The primary benefit of the tool is that it enables us to register a provider that is fully credentialed by Medicare, and to have that record fully loaded into the Program’s claims processing system within a day of their registration. It also eliminates the need for a time-consuming credentialing exercise by leveraging Medicare’s process. The provider enrollment tool ensures a fully credentialed provider is added to the Program’s provider network in a much more streamlined and expedient way.

Results

Increased registrations with minimal errors

Since the implementation of the provider enrollment tool, the Program has registered more than 1,000 providers with minimal errors. Under the former process, this took 5-10 business days. With the implementation of the new Provider Enrollment System, it now takes one day to process provider enrollments. We have received positive feedback from providers on how easy the tool is to use. With the implementation of a Federal solution-based product, the Program is now in line with other Federal payors. In addition, the new Provider Enrollment System aids in our success by streamlining how we identify, plan, measure, and track provider enrollments.

Results

Increased registrations with minimal errors

Since the implementation of the provider enrollment tool, the Program has registered more than 1,000 providers with minimal errors. Under the former process, this took 5-10 business days. With the implementation of the new Provider Enrollment System, it now takes one day to process provider enrollments. We have received positive feedback from providers on how easy the tool is to use. With the implementation of a Federal solution-based product, the Program is now in line with other Federal payors. In addition, the new Provider Enrollment System aids in our success by streamlining how we identify, plan, measure, and track provider enrollments.

[1] Through our contract vehicles, Karna provided overall communications support for DGHT. We worked closely with the DGHT federal full-time staff to develop a strategy that addresses the communications obstacles in the fight infectious global health threats. [2] Dykes, B. Effective Data Storytelling: How to Drive Change with Data, Narrative and Visuals Wiley 2019 [3] Knaflic, C. N. Storytelling with Data., pp. 228, Wiley 2015

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