Non-par provider setup is a significant challenge for most Provider Operations teams. When claims come into the system if the provider can’t be found they will generally pend. As a result, the provider must be configured to enable adjudication of the claim.
For health plans that administer Medicare and Medicaid products, there are turnaround time requirements for claims payment. This puts added pressure on the Provider Operations team to get new providers set up quickly. The configuration must also be done correctly to ensure accurate payment. Let’s look at some practical steps health plans can take to make this process easier.
Review Your Claims Matching Logic
The first thing to do is look closely at your claims matching logic. You should work to compare this logic to the “No Provider Found” claims in your queues. Determine how the claims are being submitted and whether you have identifiers in the correct places. You may experience an uptick in matching success with a few small changes.
Pay particular attention to any rules that relate to address matching for service locations or pay-to-providers. If you have gone through address standardization for the majority of your provider locations, claims that have non-standardized addresses may not match cleanly. It is recommended that you use a multi-step matching process that begins with the strictest criteria and gradually “loosens” the criteria. The final step in these processes is often the last step considered to have relatively high confidence in a good match.
Non-Provider Provider Setup Data Validation
As you get more confident that your claims are matching, you can work to automate the setup of non-par providers. Note that in most claims systems, this may mean setting up both a pay-to-provider (Billing Provider, Vendor, Supplier) and the rendering provider.
You can begin by working with your IT department to extract the key provider information from the claims themselves. This would include the names, addresses, NPIs, and Tax IDs (where applicable) of the providers identified on the claims.
From there, consider comparing the data elements received to the NPPES database. Specifically, you want to ensure that NPI numbers match the provider name and that the correct NPI type is given. You may consider standardizing the address where possible. This isn’t always feasible since providers may submit addresses that are invalid per the USPS, but where possible it may help to ensure you have as much good data in place as possible.
Consider introducing any specific validations required by your claims system at this point. This will make the non-provider provider setup process easier to automate.
Finally, it is recommended to perform an exclusion list check on non-par providers before you release claims for payment. This is important for non-par providers because they don’t go through the normal credentialing process. That means your Credentialing team has not had the opportunity to determine if the provider is sanctioned or prevented from participating in your programs. Paying a provider that is excluded can lead to hefty fines if you don’t catch it in time.
Automating Non-Par Provider Setup
Once you have validated the provider data from the claim, you can automate the setup of those providers in your claims system. You should start by working with the system vendor and your IT team to understand the capabilities. Some systems are more robust than others. You may find that some data elements – such as provider demographics and relationships – can be automated. Other data elements may require customization to automate. For example, your system may not offer integrations that allow for contract assignment. In those situations, you can choose to handle that process manually or to customize the system.
If you choose to handle any part of the process manually, ensure that you have quality control points in place to catch manual errors. This would include validating that non-par providers are set up on an appropriate Out of Network contract.
You can now work with IT to automate or customize the specific process you’ve designed. Again, be sure to build in proper audit trails, quality controls, and reporting. This allows you to troubleshoot issues in the future and fix them at the source.
In Conclusion
The non-par provider setup process is not a glamorous one. However, it is a critical component to paying claims on time and being compliant with regulations. Some experts estimate that about 25% of claims that do not auto-adjudicate are due to provider data quality issues. Many tools are available today that can help to streamline this process. Claims systems have also become more advanced in how they allow for integration. This opens the way for significant opportunities to improve this complex process.
Maven One can help you along the way. Contact us today to find out more about how we can help streamline your non-par provider setup process using the Maven One platform.