• JULY 2007 FEATURE ARTICLES •
Credentialing
Outsourcing
Business Processes
By Narciso Azurin, M.D.
A Los Angeles–based IPA achieves greater physician benefits and
an improved bottom line by employing advanced MSO services.
Angeles Independent Physicians Association
(IPA) is one of the fastest growing IPAs in the
Los Angeles area, serving several communities
in Southern California, from Long Beach
to Los Angeles. Founded in 1995 with 26 shareholders,
Angeles IPA has grown to more than 50,000 lives. This
represents an increase of nearly 20,000 lives in the past
two years alone.
Our organization’s physicians treat more than half a
million patients in the Los Angeles area each year. This
translates into more than 30,000 claims a month for the
IPA’s managed care business—a number we could not have
reached or manage alone.
Growth Challenges
In the mid–90s, Angeles IPA faced many challenges in
the way of managing administrative costs and burdensome
claims of the network. At that time, we contracted with a
relatively small services organization staffed by just a few
employees. Claims management, billing and credentialing
were handled by a paper–based system. One computer
housed all of our electronic files and none of our systems
were integrated. Data was entered manually and reporting
was limited, cumbersome and incomprehensive. We wasted
a lot of time on administrative tasks and paperwork.
These tedious processes resulted in high management
costs, increased claims processing times and a higher incidence
of errors. We realized our organization could not
grow the way we wanted, based on the limitations and
inefficiencies of our current methods. It was time for a
big change.
Choosing a Partner
In 1995, we decided to enlist the help of a managed
care services and business process outsourcer who would
provide us with a comprehensive, integrated support system
for contracting, credentialing, claims, utilization and
quality management. Based on our previous experience
with various IPAs, we became more selective in the choice
of a management company.
Because I had done business with other IPAs in the past,
I had experience working with their chosen management
companies. We compared a number of vendors, but quickly decided that Los Angeles–based SynerMed was the best
partner for us. They provided us with guidelines, directions,
insight and timely reporting. They did all the things that
we directed them to do. It was a nice fit.
Within months we employed several solutions, including
EZ Claims—an electronic claims interface that gives us a
more efficient method for claims and encounter submissions,
as well as the ability to receive payments faster. The
system helps age claims from the oldest to the newest,
arranges priority and ensures timely payment.
SynerMed manages the credentialing process for us, using
Web–based credentialing software that automates the
entire primary source verification process and manages the
complex task of credentialing, quality data and privileging.
The user–friendly, state–of–the–
art medical credentialing
software ensures we are always
in–line with the National Committee
for Quality Assurance, the Joint Commission on
Accreditation of Health Care Organizations and Utilization
Review Accreditation Commission standards. It has all the
features needed to manage our primary source verification,
credentialing applications and contracts.
The entire credentialing process is streamlined for
greater productivity and more cost–effective results. We can
now obtain reports and analysis of outstanding credentialing;
achieve provider credentialing/recredentialing; track
practitioner quality; track continuing medical education;
interface with the Office of Inspector General and National
Practitioner Data Bank; generate automatic letters and
automatic reminders; manage work flow; generate verification letters; produce appointment and reappointment
verifications; scan credentials; and, realize full health plan
delegation for all health plans.
By the Numbers
With the previous paper–based system, specialty services
authorizations sometimes took weeks for approval. They
now process in 24 to 48 hours and we’ve realized a savings
equivalent to three full–time staff members’ yearly salaries.
We are also 100 percent compliant with the health plans’
requirements. The streamlined system adds an estimated
$50,000 to $100,000 to the IPA’s bottom line per year.
Angeles IPA can now control costs
with the various providers in the network,
including the negotiation and
review of existing contracts. The use
of proper coding for medically necessary
procedures made management
more efficient, resulting in lower management
fees, improved utilization
management, and better provider,
ancillary and vendor contracting—all
of which leads to increased profitability
for the IPA.
With automated claims management
and financial services, we have
a more organized, streamlined way to
process claims and expedite payment.
Claims are now quickly and securely
sent via the Web directly to SynerMed
for processing, which allows for much
faster turnaround of claims and procedure
authorizations.
Benefits of Partnership
Since partnering with SynerMed in
1995, we have experienced tremendous
growth in physician members
and our patient base, as well as significant improvements in provider/
patient satisfaction. With computerized
management services speeding
specialty requests for authorizations,
patient procedures are scheduled
more quickly, which results in a reduction
in complaints and an overall
higher satisfaction level for member
physicians. In turn, this satisfaction
level enables us to recruit more physicians
into our member base.
SynerMed continues to identify
ways to foster our organization’s
growth, and has tailored several
solutions for our specific needs. This
includes dedicated programs in the
following areas:
Realizing full benefit of the health
plan contract: As an IPA, we want to
maximize the healthcare dollars available
to us via our health plan contracts.
The healthcare dollars are available in
the form of hospital risk pools, quality/
performance pools and member
capitation. SynerMed provides the
necessary cost and care management
needed in order for the IPA to qualify for the maximum healthcare dollars
available via the various pools. The
company also works continuously on
behalf of the IPA to secure the highest
member capitation rates available.
Hospitalist scheduling: SynerMed
develops and manages a hospitalist
on–call schedule for us, so our hospitals
know whom to call within the
Angeles IPA service center, once
a patient needs to be admitted to
the hospital.
Marketing extension program: SynerMed manages our marketing
efforts and gets our name into the
community, so we can compete with
other IPAs.
All of our systems are now handled
centrally through a taskforce and team
of representatives who meet with my
team once a month. In addition, a
marketing manager meets with us on
a weekly basis, to ensure we are leveraging
the various relationships with
health plans and hospitals throughout
the network to continually encourage
new physician enrollment.
As the healthcare industry moves
toward complete integration of electronic
medical records, Angeles IPA
will continue to look for new management
and compliance solutions.
As the industry evolves, so must we.
We must remain at the forefront of
innovation to deliver benefits to our
members, which results in the highest
possible quality of care for their
patients. We can’t afford not to.
