Credentialing and Contracting
The MVP Consulting Group will manage the payer enrollment and credentialing functions with all Payers. Credentialing functions include, but are not limited to: processing credentialing applications, updating and maintaining our credentialing database in accordance with internal policies and procedures, payer contracts, and other CAQH credentialing guidelines.
Partially Managed Option
Responsibilities of the Credentialing Team include:
- Efficiently perform all aspects of credentialing verification, including initial credentialing and re-credentialing to ensure credentials are kept current, and timely handoff and/or review and approval of practitioner files.
- Respond to all practitioners, payers, and internal inquiries in a timely manner.
- Monitor expiring licensure, board certifications, professional certifications and other expirable documents with practitioners, within the prescribed time frame.
- Collaborate with practitioners, human resources, program managers, compliance, leadership, and external agencies to facilitate and ensure smooth hand-off during the credentialing process at all stages.
- Initiate and support the Payer’s application process by sending, receiving, and analyzing credentialing documents/data to determine completeness in preparation for the credentials verification process.
- Responsible for gathering, verifying, and evaluating highly confidential and sensitive health care credentials data consistent with guidelines and accreditation standards.
- Maintain the Payer system updates and provider directory, provider and location information, submission to Payers.
Fully Managed Option
- Our firm will develop market-level contracting strategies in alignment with finance and other operational areas of the organization. Develop a local, state-level, and national strategy relative to business development and strategic positioning as it relates to the payer and contracting goals.
- Manage the payer contract process, approvals, implementation, and contract management to include:
- Payer contract and rate negotiations, including Single Case Agreements
- Facility program, group or system enrollment and contracting with payers,
- Contract approvals process, contracting signing and sending to payers, implementing executed new payer contracts or amendments
- Establishing the payer contract prioritization and targets to yield optimal patient referrals and financial targets
- Establishing target payer rates to optimize financial profit targets
- Establish and manage the payer contract and reimbursement reporting system to leadership and internal staff to ensure optimal contract adherence and patient referral approvals, meeting revenue returns on all payer contracts and rate opportunity analyses.
- Responsible for developing and recommending strategic contract initiatives, desirable reimbursement methodologies, rate analysis, predictive modeling and other contract arrangements that drive incremental volume, profitability, and value.
- Ensure timely renewals of payer contracts and that all contracts are implemented effectively.
- Explore or develop new payer-provider pricing methodologies in support of new program or clinical business planning including capitation, risk arrangements, value-based care, pay-for-performance, and shared savings.
- Develop and maintain strong relationships and partnerships with payers to advance system goals. This requires being available at all times to promptly respond to any Payer’s email, phone calls or task requests.
- Develop aligned relationships with leadership teams by facilitating and maintaining strong working relationships with internal leadership, departments, operations, clinical and individual staff, supporting them in our payer strategy. This requires being available at all times to promptly respond to any Payer’s email, phone calls or task requests.
- Act promptly on management and internal inquiries, external inquiries, questions and requests regarding any payer contracts, credentialing, payer issues, claim issues and other payer items.
- Participate in the opening process for new locations and programs to ensure payer contracts and enrollments are optimized.
- Represent the system as a leader in healthcare industry association(s) and organization(s) to support the strategy.
Why Choose MVP Consulting Group for your Credentialing and Contracting Needs?
Here at MVP Consulting Group, we have a proven process for satisfying client organizations needs when it comes to key credentialing and contracting operational functions. Our approach combines strategy, management, and ongoing compliance to meet the changing landscape of healthcare credentialing and contracting.
Inquire about our services today! Your experts in credentialing and contracting are here to bring added value to your organization!
