Protecting the Revenue Cycle With Credentialing with Brent Althoff, Director of Credentialing Operations at MedTrainer

[00:00:01] This podcast is produced by Outcomes Rocket, your healthcare-exclusive digital marketing agency. Outcomes Rocket exists to help healthcare organizations like yours to maximize their impact and accelerate growth. Visit outcomesrocket.com or text us at 312-224-9945.

[00:00:29] Hey everybody, Saul Marquez with the Outcomes Rocket and I'm so excited to share this five-part episode series that we've done with MedTrainer called Rethinking Compliance. Through these five episodes, we give you what you need to transform your best practices and approach to compliance. So excited to share this with you and to learn more about the series and about what MedTrainer has to offer.

[00:00:56] Visit outcomesrocket.health.com and see it in the show notes below. Today, I have the privilege of an outstanding guest. His name is Brent Althoff. He is the Director of Credentialing Operations at MedTrainer, the partner that we're doing this series with. Brent has a deep array of experience in the credentialing space with working with various different providers,

[00:01:24] the oral health space, as well as payers like Optum. And so I'm excited to have him here on the podcast to shed some light around compliance and things that we could be doing to accelerate it in healthcare. So Brent, so grateful that you're joining us today. Saul, really appreciate being here. Absolutely. So look, let's start with a fundamental question. What are key drivers behind the need for healthcare's need to focus?

[00:01:53] And provide an overview of the credentialing process in healthcare and why it's crucial for healthcare organizations. Sure. One of the biggest things about credentialing is its multifaceted base. It's always complex. It's a really broad term across the industry, whether you're getting credentialing with a healthcare organization or whether you're getting enrolled with a payer. And a lot of people refer to that as getting credentialed with an insurance payer.

[00:02:23] So there's always kind of a broad term to it. The other hard parts here with credentialing and the nuances are nobody's the same, right? Each state has their own differences along with all the payers. No one's the same.

[00:02:38] Now, 95% of it's probably close to being the same, but there's always a 5%, maybe even 10% nuance where whether it's state regulations or even just the provider differences that cause us to be different for every single provider, every single group, every single payer. So it adds to kind of a little bit of a difference that makes everything unique, even though the majority of it is the same. You have a really unique perspective, right? You work for a health system.

[00:03:06] You spent a few years at a major health insurance company. How do things look like from the payer side? The fundamental piece that a lot of healthcare organizations, whether it's a small group practice, I worked for a safety net hospital in Minneapolis. Each one of those has the feeling that the payers are trying to withhold, trying to not pay them. And realistically, when it comes down to it, the payers have to follow a strict process.

[00:03:36] Now, some of that's government-based. Some of that's interior basis to what they have to meet for their own regulations. But a lot of it comes into like MPS on net promoter stores. It's one of the big key driving factors behind the insurance payers that a lot of people don't see. Basically, it's the detractors, you know, who's actually promoting you. So they do lean heavily on that.

[00:04:05] And it's something outside of the normal health scope as far as credentialing in a group or a hospital that they don't really lean on. Because you're already in a normal clinic setting or hospital or group, you're normally interacting with those providers where it's really easy. You know them by name. You've probably met their spouse. You know, they've talked about their pets. Whatever it may be. Or even, you know, just that feel where you know that person one-on-one.

[00:04:32] Both sides of that, from that payer's perspective, they don't know those people as well as you do. They don't know them. So they're looking for, you know, feedback on how the provider's doing and like how the process is working for them if things are running smoothly. So they use that MPS score to really kind of drive their focus.

[00:04:51] And the other parts here with the healthcare, it's every single one of the payers has a different process and a different piece that moves them in a different direction. So they have to follow. And the hard part with the payers is that you have to follow everything, you know, state-based. So states might have their own regulations. They might have different pieces for the provider that they can accept in one state. California's nurse practitioners actually don't have licenses. They actually have certifications.

[00:05:19] In Minnesota, where I'm based, they have to maintain their RN with their MP. And they also have to have a certification. So there's so many different variables in with this that make this kind of convoluted at some points in time. So when you're working in, for us, when we're working in Minneapolis, it was really easy for us to be able to work because we're only dealing with, you know, Minnesota-based. One state. Yeah.

[00:05:46] It's very easy where, you know, the payers are working across all 50 states. So it becomes a lot more, like I'm saying, convoluted for them to be able to pick up on everything and know everything. Because, I mean, if you start doing the math behind it, you get into 50 states times 30 different providers. And, you know, all of a sudden, the knowledge base there just jumps through the roof. So it's a little harder for them to be able to do it.

[00:06:12] But it's still being able to – the big part here is being able to communicate out what the payer actually needs and having the hospitals. And that's – I think that's kind of the downfall a lot of the times with the payers. It's here's the process, but they don't go into a lot of details. And I think that's kind of the chasm that's in between the groups and the payers. So then is part of what you guys do with the process is help the payers communicate requirements more effectively?

[00:06:42] Is that part of it or no? It's really pushing the payers into the idea of, like, being able to communicate better and holding them accountable in certain areas. I mean, that's the best term that we can use is just accountability. And certain groups, obviously, we have FQHCs that, you know, they're based off the federal governments, what they're funding. But they have certain requirements.

[00:07:06] And they have managed care organizations that actually work as a subpart to the insurance payers that deal with the Medicaid based on, you know, the different states. So those MCOs have certain requirements that they have to meet because of state regulations to be able to keep that managed care organization funding and to keep that contract in place. So they have to play by the rules, which for the organizations, the healthcare organizations is great because they have some teeth on this.

[00:07:35] It's not just waiting and waiting and waiting. They can hold people accountable. So it's good for both sides, honestly, in the end, even though people don't like it. Workflows with credentialing could be super complex. Could you share some specific automation tools or strategies that have proven successful in credentialing? And really, bottom line is, how do they impact revenue cycle, right? Because that's what a lot of people listening to this series care about.

[00:08:03] And that's something, you know, a med trainer that we're always constantly trying to do, even outside of that. I mean, our competitors, whoever it may be, it's trying to find that piece to be able to have all the information in one area so you have that source of truth. That's a huge industry term that is used all the time. What's our source of truth, right? You know, 20 years ago, before everything got into the tech area and we were able to, you know, start moving in a better direction, it was paper.

[00:08:30] And every time I hear paper, I just cringe a little bit inside because I use the paper. I've done that. I've submitted the applications through fax or by mail. And, oh, bad feelings come up with that. But the automation piece is to be able to drive us forward. So small things like being able to have that source of truth, being able to pull that information out quickly.

[00:08:53] If you're talking about, you know, the data that you have in the system or even in, you know, in a basic spreadsheet, how can you get that information out quickly, get it into an application, get it sent? Whether the application's in email or it's in a portal or, you know, if you're using Medicare through PECOS, like how can you get that information out? So having it first and it's one place, safe, true. Second, how can I get it out quickly? Because the third piece is the faster you get that out.

[00:09:22] If you think about, you know, a provider working, you know, five days a week and seeing patients for five days. Now, I can speed that process up for five days. Look at that from a revenue perspective. You're able to bill those claims and get reimbursement for those five days. If I can do a five days quicker.

[00:09:39] Now, if you have a, you know, a position or a provider doing that for five days, they're probably looking at somewhere between 2,000 to 5,000, depending on the type of provider is and the services that they are providing. So in that five day period, you're looking at 10,000 to $25,000 in revenue. And that's five days. Now imagine if that's 10 days, right?

[00:10:02] Now imagine that's 30 providers or big, big organizations like the one I worked in Minneapolis. That's 1,250 providers. And now those numbers, you know, are starting to become astronomical at that point in time. You're looking at huge swings in revenue. So the credentialing piece with the payers is where you can make the biggest difference.

[00:10:24] So if you're able to automate that, move it quicker, be able to follow up, send notifications, follow up emails, you know, to the actual payers, you can move a lot quicker. And that just drives your revenue at that point. Really just keeping everything up to date, making sure that it's being sent to the payers. And all of that today, as I understand it, is very manual. You guys are automating that process.

[00:10:49] And that's the piece that every group should be doing, whether it's two providers or it's, you know, 2,000 providers. The idea is to be able to have that source of truth, move it out, and get it moving forward. But the small pieces here are the notifications, the reminders, right? Everybody has got an outlook or, you know, whatever source that you're doing for tracking. The credentialing space and the actual software piece of this is able to send notifications. I mean, we can send follow-up emails to the payers.

[00:11:19] And that's not just mentoring. That's across, you know, the credentialing space for anything. You should be able to do these things. You should be able to send the notifications. You should be able to get notifications when things are coming due. We have, I mean, the primary source verifications that we have to maintain, whether it's licenses, board certifications, life support certs. I mean, there's also provider liability insurance that we have to maintain on a yearly basis.

[00:11:46] There's all these things that can put you out of compliance, that can, you know, take you out of accreditation very quickly if you don't have these set up. So having the notifications, having it in one area, it boosts your ability to be able to move quicker, yet at the same time be flexible with any kind of information that's coming in and out of your business. Let's talk about how C-suite can help support credentialers.

[00:12:13] From your perspective, how could the executive leadership team help them enhance efficiency and revenue? The biggest way in a lot of times in being a credentialer, and I've done that, I've been the basic person on the bottom end and the entry level. The basic way you can do this is being involved when you need to be involved and staying out and not becoming a blockade or a gate when you don't need to be.

[00:12:38] And that's the complex part of this is really knowing what you can add value in as far as with your, you know, your policies and procedures, staying to your, you know, your restrictions, your regulations, but also making sure that you're not adding more to it than you need to, right? If your regulatory requires you to have five years worth of work history, you know, and you as an organization are requesting seven, really ask yourself why you're doing that.

[00:13:06] Making sure that you understand that, you know, you only need five years. Why are you doing seven? Is there something, you know, is there some reason that you need to do that seven? Or are you just adding it to add a higher standard for no particular reason? Other areas, it's just really making sure as a provider, you're providing that service to that patient. And that is your primary focus here in your journey through your career as a provider to provide that care.

[00:13:33] And it's hard sometimes to be able to get that information or to get the providers to buy into the credentialing process. So having, you know, an executive leadership team or even a physician champion or a provider champion for that matter, to be able to help drive that credentialing process, that's one of the biggest things from either a credentialer or a credentialing company such as MedTrainers to have somebody on the inside to be able to help drive you.

[00:14:00] That in itself, it's so welcoming and it gives you the ability to be able to move things when at points in time you can't. And that's kind of the bad part about being a credentialer every once in a while is you don't have that ability. So being able to have that partnership, to have somebody come alongside you and help move that forward, it's so crucial in what we're doing.

[00:14:23] Making sure that the standards, everyone is holding their organization from a compliance front aligned to the standards that need to be in place, not necessarily something that has been. So it's like, it's worth examining. Wouldn't you say like what the standards are? A hundred percent. And that's the thing also, like listening, actually listening to what not only your medical staff is saying,

[00:14:50] your credentialer is saying, being able to reevaluate things like what you just said, like being able to take a look again and be like, are we just doing this for the sake of doing it? Or are we doing it with a purpose and making changes when you need to every two years? I mean, you should be reevaluating every two years of what your credentialing process is. I mean, look at COVID. A lot of the payers changed out their applications to meet the new requirements.

[00:15:15] Are you changing out your policies and procedures and your requirements based on that? I know a lot of the organizations that we work with right now as our clients, they've added in COVID sign-offs to all sorts of different areas for that. Work from home standards, a lot of telehealth abilities. So there's so much that changes in that. And that's just one small piece.

[00:15:40] I mean, we're not even talking about what's different with the payers or what the government's now requesting for the state. There's so many different things that you need to reevaluate. And two years, I think, is a good time period. I wouldn't want to go over that. And you could do it every six months if you want, but then you're just kind of getting in a spot where you really need to. And two years is kind of that good window of, we've went a while, let's reevaluate. And these reevaluations, I think, are critical for all of us to consider.

[00:16:10] And even outside of credentialing, I know many of you guys that are listening, maybe you're thinking credentialing, okay, maybe not for me. But frankly, when you think about what you're doing, obviously you're a med device company, you're thinking about this. But if you're a business, you got to be thinking about your systems and your processes. And I think that two-year rule that Brent is alluding to is a healthy window to take a look at our SOPs and the ways that our companies run. What did you say, Brent?

[00:16:40] Yeah, I mean, some of them, I mean, the good ones that we work with, and I'll quote good ones, they're doing it on an annual basis. Annual, okay. To make sure that they're, but a lot of this comes into, do you have the time, do you have the resources to do this, right? A lot of the bigger corporations have a quality assurance team, and some of the groups we work with are 10 providers. They've got seven people on staff there, right? So do we have enough time? Do we have enough resources to be able to look at this?

[00:17:10] So I mean, to go back and refine even more, I would say between one and two years. That's the thing. Okay, I like that. I think the lower than a year, you have to, why are you doing it more than once a year? Do you have something that you need to be looking at intrinsically inside? Like, you're not prepared. You haven't had a legal team review at, you know, do you have all your ducks in a row? Yeah. No, that's awesome. Hey, Brent, so, so, you know, there's a ton of challenges, right? And a lot of people struggle with this.

[00:17:39] When it comes to credentialing, can you give us some examples of those challenges? And then some guidance on how our listeners could navigate to overcome these hurdles? Sure. One of the biggest things that we're seeing now, and we've probably been seeing over the last 10 years, but even more so now, it's been flexing even more than normal. It's just the credentialers that are doing the credentialing aren't always doing credentialing full time, right?

[00:18:08] You have people wearing multiple hats. You have people doing administrative assistant work. Or a few clients we have, we have the COO supporting the credentialing process. As they move forward. Then the growth in healthcare, whether it's through mergers or whether startups with the behavioral health sector, that has been growing immensely over the last, you know, five to 10 years.

[00:18:35] So that piece of multiple hats and having people that aren't necessarily normally in the credentialing world, we're seeing that more so than ever. And credentialing in itself, you don't go to school for credentialing. You don't start off going, I really want to get into credentialing. The credentialing scope in itself, you kind of fall into it, or you're maybe brought into it against kind of your will a little bit with the needs.

[00:19:02] But that's probably the first thing is just all the hats that people are wearing, right? That I'm doing this, I'm doing that, I'm accounts receivable, accounts payable, I do credentialing. That's probably the biggest thing we see. The second part is just unrealistic expectations. What does that look like from your team? What are your unrealistic expectations that you have for the payers? Thinking that you can get stuff done in two weeks when that's not the case.

[00:19:31] Having people be able to just think they know things and it's always going to be this way when things change all the time. Applications, requirements. If you look at the accreditation bodies and their standards, those change every year as well. Not in drastic ways, but small ways that still will impact you if you're not prepared. So that's one of the biggest, those are the two biggest things. Another area here, I probably got a top four.

[00:20:01] Yeah, let's hear it. The third area is just the ability to be able to transfer from paper eventually at some point in time. Now, most of the industry has done that, but there's still some, especially the small organizations that are still using paper because it's not cost efficient for them to be able to switch yet. But the thing I would say is not being terrified of making that progress or that shift.

[00:20:28] A lot of the accreditations and different organizations, even the payers, have small windows for you to be able to transition from that paper. And a lot of the different areas, whether it's scanning companies or even consultants, have made this process a lot smoother. There's a lot more true and tested ways to be able to do this. Just communicating with other groups that have, you find pain points that maybe they saw that

[00:20:56] are, you know, that you haven't thought of yet. That transition though from paper is probably the biggest thing that people get scared of. And it's not the time to be scared now. Like 10 years ago is probably, but not now with all the different automation tools, consulting teams, all that. And the last one, number four that I would have. Yeah. Just being prepared. That is probably one of the pieces here that we can't stress enough, right?

[00:21:26] It's project management 101, right? Being prepared, doing the work up front, doing all your checks and balances, having everything in your policies and procedures, making sure that you have everything that you want implemented and then going after. But it's being prepared, being informed. Those are the areas in which that rounds off the top four to me. And the things that we constantly see from people when they come in, they come into us, they're having, you know, Hey, we'd love to start working with you.

[00:21:54] And then we asked them, what would you like us to help you with? What areas would you like us to move in? What direction? And they're like, I don't know. What payers do you want us to enroll you with? The good ones. And unfortunately, that's not really helpful to us. So being prepared from the aspect of the healthcare group, it's just, it's paramount in the industry. And you, and I know it seems a little, you know, a little, little funny or a little indifferent

[00:22:24] that people would be coming with that. But we have, we have, you know, providers that are coming here that want to start their own business or want to do that. And they have the medical experience to be able to do it, but they might not just have the business aspect tied down yet. So we see that a lot. So being informed, being prepared is huge. We'll provide a summary of, of, of these top four from Brent, as well as all the things that we've discussed on today's episode in the show notes. So, so definitely make sure you check that out.

[00:22:53] This has been really insightful, Brian. I've, I've enjoyed the conversation. I think this is a great way to, to really open up the series. Looking ahead, can you provide insights into emerging trends in credentialing? You know, how can healthcare institutions stay ahead of the curve and optimize this process further? This is the hardest part that I see happening now. And it's probably the, the, the dark secret that no one really wants to talk about because

[00:23:23] that's, oh, we're not on paper anymore. We're in digital. Don't complain about it. But it's, it's, it's the piece where it's probably the hardest thing to do right now because everybody has a different platform. If you want to, you know, send a, submit an application, there's a portal that you have to log into. Now I have to take that information out of my digital capacity, put it in another digital capacity and to be able to have it. Now, if I take it from mine and there's no, there's no API, there's no, you know, connection, there's no contract between the two.

[00:23:52] I'm stuck entering that again manually. So we have all these different hack systems, but they're not talking to each other. And, you know, it's, it's, it's hard because there's a lot of companies like, Hey, now we have to develop all these APIs and all these different pieces. How are we going to send this? And, and there's certain ways we can get around it, right? We can send CSV files. We can send those types of those pieces.

[00:24:18] We can also upload information such as PDFs that, you know, they can do the screenshot and grab, but it's the multiple systems that it's, it's really the driving force and how we're going to communicate going forward. And, and maybe, maybe AI is going to, you know, be solving that hopefully in the next, you know, two, three, five, 10 years where, you know, we're going to actually have that, you know, the systems talking to each other and filling out that information.

[00:24:43] But that's, that's the, that's the dark secret that no one wants to talk right now is how we have all this technology, but how do we get it to work together? And how are we able to move? Cause that's, that's the next step. If we can get that working, the sky's the limit here, as far as, you know, what we can do for providers, what we can do for patient care, uh, and what we can do for all of our organizations to make life easier. I get super excited just thinking about that, that interoperability and what it could mean

[00:25:12] for, for, for really, you know, patient care and profitability. Uh, this, this, this is just, uh, uh, the beginning of it. And, and look, you've offered some major value today. I want to thank you. If you had any one takeaway that you wanted to leave our listeners with, what would it be? Staying informed, being prepared. Like those are those, those two things. I know that's, that's a two thing piece, but just staying informed, right?

[00:25:40] Knowing what the payers are requesting, staying with what the government has. There's different bills coming out with all sorts of different things, whether it's, you know, during COVID, we have small examples of the ability to be able to do things differently because of COVID. Like, but there are a lot of healthcare organizations that didn't know what was happening. Like they didn't know they could do this and they, and those things that just staying informed and being prepared are the paramount pieces here that are going to drive success.

[00:26:07] Whether again, like you said, and patient care, provider health, mental health for them. Uh, and in your revenue, like those, all three of those things, if you're winning, like the sky's your limit and people are going to want to work with you every day of the week. Stay informed, be prepared. Uh, I I've been impressed with the work that med trainers doing to really kind of keep their community, their customers, uh, informed and prepared.

[00:26:34] So definitely tap into the resources they offer and, and certainly take a look at the show notes for a lot of the insights that Brent shared today. Brent really appreciate you jumping on, on this series. It's all more than happy to do. Thank you. This podcast is produced by outcomes rocket, your healthcare exclusive digital marketing agency.

[00:27:05] Outcomes rocket exists to help healthcare organizations like yours to maximize their impact and accelerate growth. Visit outcomes rocket.com or text us at 3 1 2 2 2 4 9 9 4 5. Thank you. Thank you.