A multi-specialty facility overcame the internal credentialing software issues and successfully submitted 150+ applications

The Client

A large-sized multi-specialty medical practice in the U.S.

Challenges Faced

Unable to add manage all the provider applications and/or each payer/provider status
Problems in maintaining the appropriate step in the credentialing processes
Credentialing process was time-consuming
No credentialing software to help manage or provide the visibility required
Denials due to “out of network” were rapidly rising
Providers felt like the company was letting them down with credentialing services

Plutus Health's Plan

Plutus Health's credentialing experts started the project with root cause analysis of the problems. We had a brief discussion with the client and detected the following problems.

Problems Detected

Lack of application information.
Having incomplete Physician/Group enrollment applications.
Not updating and verifying information in a timely fashion.
Failing to report adverse actions to the National Practitioners Data Bank (NPDB). Physicians and facilities that fail to report adverse actions to the NPDB and withhold critical information will not be able to complete medical credentialing requirements. The NPDB requires reporting of the following actions:

Medical malpractice payments
Federal and state licensure and certification actions
Adverse clinical privileges actions
Adverse professional society membership actions
Negative actions or findings by private accreditation organizations and peer review organizations
Healthcare-related criminal convictions and civil judgments
Exclusions from participation in a federal or state healthcare program, including Medicare and Medicaid

Steps followed by Plutus Health/Solution provided:

Plutus Health’s experts detected the reason for all the problems and started working on delivering solutions to overcome each one.
Plutus Health immediately set up a team of developers and designers to provide support.
With the help of the latest technologies, Plutus Health added new features and made the application more performant and easier to use.

Results

The client was satisfied with how quickly the Credentialing situation was turned around and now their providers are “in-network”.
Credentialing related claims denials were dramatically reduced.
Physicians are now able to see more patients with the Health Insurance companies that they are on par with.
Patients are happier because they are now receiving their “in-network” insurance benefits.
Successfully submitted 150+ credentialing applications.
All providers are now “in-network” with their region’s main insurance companies
Provider, employee, and Patient satisfaction has increased tremendously.
Faster turnaround times with insurance reimbursements

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