Enrollment: When Claims Are Submitted Under the Wrong NPI and Other Compliance Tales

When an employee at a community hospital was injured in a fall and immediately sidelined, the medical staff credentialing and privileging processes came to a screeching halt. She was the only person at the hospital who understood the process, working tirelessly on it year after year as CEOs, chief financial officers and chief medical officers came and went. The hospital had to scramble to rebuild its privileging and credentialing capacity and was visited by an auditor in the thick of it.

This is a cautionary tale of the risk of investing too much expertise and responsibility in a single person. If he or she is suddenly unavailable, part of the hospital’s operations could be temporarily crippled, said Susan Prior, president of VantagePoint HealthCare Advisors in Hamden, Connecticut. “There’s a lack of continuity if the person unexpectedly leaves the organization,” Prior said March 30 at the Health Care Compliance Association’s virtual Compliance Institute. “The C-suite wasn’t sure what to do. They had a credentialing committee meeting and had providers who needed to go through the process and didn’t know where to start.”

When Prior arrived to help, she and the executives combed through the employee’s desk and computer. It was apparent the employee was “the duchess of solitary intelligence,” said Prior, as part of a theme of presenting compliance problems as versions of fairy tales. “This one person held the keys to the entire organization.” Six executives couldn’t make sense of the piles of paper. “It was a real mystery,” she said. “If they didn’t unravel what they had there, they would be up a creek.”

There are multiple risks of having paper records or hybrid processes only understood by one person, Prior said. They include a lack of audit trails, untimely recredentialing, overlooked changes to licenses, malpractice claims, and exclusion from Medicare and other federal health care programs. “What we were trying to do with the organization was spin that paper into gold,” she said. “There was a hidden treasure of paper on the island that probably would not have been discovered without that unfortunate event.” The credentialing information was saved to the employee’s desktop, which wasn’t backed up.

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