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Smarter Credentialing Strategies
71 Plays21 days ago
Nyleen Flores, CEO of MedElevate, and Shannen Reyes, President of Advanced Quality Compliance, are joining us today. With decades of experience between them, Nyleen and Shannen have helped countless surgery centers streamline their credentialing processes, reducing risk and improving patient safety along the way. In this episode, we unpack common misconceptions, share tools and systems that actually work, and chat about their brand-new podcast, Credentialing Chronicles.
Later in the episode, I’ll walk through our latest Data & Insights spotlight. You’ve probably seen our full State of the ASC Industry Report, but we’ve just released 12 new benchmarking reports focused on specific specialties. Today, we're focusing in on Cardiovascular ASCs—with insights from 108 centers and roughly 9,000 cases.
Resources Mentioned: https://www.hstpathways.com/specialty-data/cardiovascular
Brought to you by HST Pathways.
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Transcript
Introduction & Podcast Format
00:00:01
Speaker
Welcome to This Week in Surgery Centers. If you're in the ASC industry, then you're in the right place. Every week, we'll start the episode off by sharing an interesting conversation we had with our featured guest.
00:00:12
Speaker
And then we'll close the episode by recapping the latest news impacting surgery centers. We're excited to share with you what we have. So let's get started and see what the industry's been up to.
00:00:27
Speaker
everyone.
Discussion on Provider Credentialing
00:00:28
Speaker
Here's what you can expect on today's episode. Nyleen Flores, CEO of MedElevate Solutions, and Shannon Reyes, president of Advanced Quality Compliance, are both on today to talk all about provider credentialing.
00:00:43
Speaker
Nyleen and Shannon both have decades of experience with credentialing and have helped countless surgery centers better organize their credentialing processes, ultimately helping them mitigate risk and keep patients safe.
00:00:54
Speaker
Together, we'll go through common misconceptions and the best systems and tools to use for credentialing. And if this isn't enough credentialing info for you, we'll also cover the new podcast they recently launched together called Credentialing Chronicles.
00:01:09
Speaker
After my conversation with Nyleen and Shannon, we'll switch to our data and insights segment. You're likely familiar by now with our full state of the industry report, but we've recently released 12 new benchmarking reports that are shorter, solely focused on the data, and take a deeper dive into one single specialty at a time.
00:01:28
Speaker
So today we're spotlighting cardiovascular ASCs. So I'll walk through 10 key metrics from 108 centers, that represent roughly 9,100 unique cardiovascular cases.
00:01:41
Speaker
I hope everyone enjoys the episode, and here's what's going on this week in surgery centers.
Hosts Introductions
00:01:50
Speaker
Nyleen, Shannon, welcome to the podcast. Hi. How are Good, good. Can you please tell our listeners a little bit about yourselves? Yes. Yes. So I'm Nyleen and have been in the ASC space probably for the last six years or so.
00:02:10
Speaker
I to run a surgery center. I've been doing credentialing for about 17 years and met Shannon about a year ago. and so we became fast friends and decided to do a really fun endeavor together since we are in love with this thing called credentialing. Shannon, what about you?
00:02:32
Speaker
I've been in credentialing same for about 22 years, came out of corporate America and opened up my CVO this year, our CVO celebrating 10 year anniversary, women owned baby NCQA certified, all that good stuff.
00:02:50
Speaker
Congratulations. That's awesome.
Credentialing: Process & Misconceptions
00:02:52
Speaker
So given all of that expertise, can you please give us the 30 second overview of what credentialing is?
00:03:02
Speaker
So credentialing, that's a lot in 30 seconds only because the word credentialing is actually used for different kinds of credentialing. So there's credentialing that a lot of people know.
00:03:14
Speaker
Yeah. With like insurance companies. So you have to credential with an a insurance company to enroll, right? So it's like an enrollment, it's called payer enrollment and that has a credentialing process.
00:03:25
Speaker
And then there's credentialing where we are checking and verifying the credentials of the doctor that walks in to see you. Did I miss anything, Shannon? Yeah, the latter is more done on the hospital surgery center approach. And it's just ensuring that the doctor has good peer references, good education, that those things can be verified, licensure, and that really looking for board actions, NPDB actions, things of that nature on the latter part of the credentialing that Nyleen is talking about.
00:03:56
Speaker
Perfect. So what are some of the most common misconceptions that surgery centers have about credentialing?
00:04:05
Speaker
It's easy. Yes. My software does it for me. i have a database. Yeah. I got sold this expensive, awesome database.
00:04:18
Speaker
Yeah. The computer does it for me. hey ah Exactly. I think really too, that it's just that it needs care. It needs organization. It needs constant monitoring. And that's something that's very important in credentialing.
00:04:33
Speaker
And I think some sometimes that's lacking and it creates a little discourse.
Tools & Systems for Credentialing
00:04:38
Speaker
Sure. So are there specific or just general kind of systems and tools that you would recommend for successfully tracking credentialing tasks, deadlines, all of that?
00:04:50
Speaker
Well, obviously if you have CVO, they do it for you. so yes there's that option. You can hire a third party service to do it for you or an agency that can run it for you. So that's one option. The other option is ah having a database, of course, to monitor and alert you when things are expiring, things like that.
00:05:11
Speaker
But most importantly, it's really educating your administrator, especially in a surgery center world. and or the business office, whoever is handling the task that we are calling credentialing and verifying that a doctor is clinically competent to perform along with your clinical leadership to ensure that they're reviewing peer review and ongoing monitoring of these doctors.
00:05:35
Speaker
So having a good system processes and then any software that can help you with that is um obviously the best way to do it. And I'd say keeping up to to keep up with it.
00:05:48
Speaker
It's not a one and done. You gotta, it's ongoing every month. We're looking tracking. Sure. Do you find that, is it possible? what doesn't sound like it would be a best practice, but is it possible for a surgery center to manage this in-house without any software or tools to support them or not really?
00:06:09
Speaker
Well, what we find is that a lot of people are doing that currently using an Excel spreadsheet document. That's what all of us used to use back in the day before all of the thousands of credentialing softwares came on board. And so, yeah, it's possible. People are doing that every day and software companies are beating down their doors saying, let me get you over to this software.
00:06:27
Speaker
But is it advisable? but Depending upon your provider staff, if you have five providers, then yeah, it's completely possible. If you have, let's say you're tracking 20, over 20 providers, you guys are anticipating growth, things of that nature.
00:06:39
Speaker
then at that point, you're gonna need to go ahead and transition over to a software and remembering that the software doesn't come with the support of managing the software. So you have to have a dedicated person either outsourced or on staff that knows your software, knows how it works, knows everything that's coming in and out of that software.
00:06:57
Speaker
Yeah, for sure, definitely.
Organizing Credentialing Systems
00:07:00
Speaker
Gotcha. So if a center currently is behind or disorganized with their credentialing or just has concerns, what is the best way for them to get back on track? Where can they start?
00:07:12
Speaker
Even like a company like Nyleen's, they look at messes like that. And they say, this is what you should do. And then they advise after the assessment of say, hey, maybe this part you can outsource. Hey, maybe this part we can look at a different biller. Your biller's not really doing the best.
00:07:26
Speaker
And they really organize all that for you. That's the greatest approach. The other thing is bringing in somebody that's familiar with the credentialing world and being able to give you that assessment.
00:07:36
Speaker
I think a lot of times people think they know what's going on. But then when they call all the payers and they realize that the person never submitted applications, they're getting denials, their AAA HC is knocking down the door and they don't have files. It becomes a red fire alarm at that point.
00:07:51
Speaker
And you don't want things to get to that, my love. you You don't want it, Erica. Yeah. Yeah, the last thing you want is that as a surveyor to come in and be like, oh my goodness, where is the NPDB before privileges were granted? Where's your privilege form?
00:08:05
Speaker
So the problem is if you look at the publications from the accreditors, so whether that's Joint Commission, DNV, ACHC, Triple HC, all these accreditors that are monitoring our surgery centers and we pay so much money to be accredited by,
00:08:23
Speaker
Their number one deficiency is always credentialing when it comes to surgery centers. And that's because it's not given the level of attention. And again, I'm going to tell you a hundred percent. That's my opinion, even though it's proven with documentation, but let's just say it's number one, ah most ignored.
Importance of Credentialing in Surgery Centers
00:08:41
Speaker
And if you ask me, one of the most critical roles within a surgery center to ensure that we're providing best practice and safest care to our patients.
00:08:52
Speaker
And I would listen to Nyleen, she literally has about 12 or 15 certifications behind her name. I'm just saying, she is a certification directory of all certifications. So if you're going to listen to somebody, it would be Nyleen Flores, okay? Yes.
00:09:09
Speaker
Every time I go to tag you on something in something, Nyleen on LinkedIn, I get all the acronyms after, but well-deserved. It's three sentences long, right, Erica? That's what I tell her all the time.
00:09:23
Speaker
But we love you and all your knowledge. Nobody else does that. Nobody else has that. So what are some of the biggest risks or consequences of poor credentialing practices?
00:09:38
Speaker
There is a lot of crazy stuff happening in surgery centers because it's more of I'm your buddy. I'm buying in I have rights because I own part of the surgery center. I can do whatever I want.
00:09:52
Speaker
And so what happens is while we understand that physicians do a lot of training, That doesn't necessarily mean that an orthopedic surgeon can take out a gallbladder, right? So surgery isn't surgery.
00:10:08
Speaker
So there has to be processes in place to not only check doctors initially, but check them ongoing. We can get into some juicy stories, but there's things that change. And that's why Shannon was talking about like ongoing problems. Give you an example, ah doctor that's aging.
00:10:30
Speaker
He's a GI doctor, for example, he's aging and he went from not wearing hearing aids to having to wear hearing aids, right? So that's a change in status that can directly affect patient care.
00:10:43
Speaker
And in the case of one doctor out of Florida, He ended up perforating a bowel because he didn't hear somebody saying something. So he injured a patient, right?
00:10:54
Speaker
Because it was a change and that can all be tracked through credentialing. and peer review. So that's one of the reasons and monitoring. So things change, education changes, the students and the doctors that are coming out of school now are learning very different techniques and equipment than doctors who've been practicing for 30, 40 years.
00:11:17
Speaker
So
Creating Credentialing Chronicles Podcast
00:11:18
Speaker
I don't know, Shannon, any other biggest consequences? Yeah, I know. Nyleen's always going to talk to you about privileges all day because she, that is her passion. no yeah I know, yes. I'm going to talk to you about monitoring and background checks and making sure sanctions and making sure that yes, you do a background check when that provider first comes on.
00:11:37
Speaker
But there's a lot of people that don't like Nyleen said, this is my buddy. They come in and we've been we've known them forever. But then you find out you do a background check. They've had three DWIs or whatever that is. You start seeing patterns on behavior that can directly affect your surgery center. And then you unknowingly, right, because you're not doing due diligence, are bringing in a risk to something that you're trying to grow very hard. And you don't want to do that.
00:12:02
Speaker
And so that's what I say. I say do your initial background checks, which are very important. But every time on recredentialing, background checks should be included as well because things change in that area. And you want to know the risk that are in your surgery center.
00:12:17
Speaker
Sure. Those are such interesting examples, like especially the hearing aid. I would never even consider something like that being part of credentialing. Just think, are your licenses up to date? You have all your credit. Are we good there?
00:12:29
Speaker
Kind of what sounds like most people think you're just checking the box and you're not really thinking of all these other criteria that go into it. Yeah, exactly. Yeah. So you guys recently launched your own podcast, Credentialing Chronicles, to cover this.
00:12:44
Speaker
Why did you feel it was important to do so? right, Shannon, you start off. Yeah, definitely. i love credentialing. And the one thing about credentialing is that we are all held, all medical staff professionals, that's what we fall under, are held to a very high level of confidentiality and privileged data.
00:13:06
Speaker
And so because we're held to those very high standards, there's really not a way or an avenue to talk about it You really can't go to your husband and say, oh my God, guess what this doctor thought. He don't understand what you're talking about. You really can't disclose any names. And so it just becomes like this loop of just keeping it in your head and just moving on with your life.
00:13:24
Speaker
But at Credentialing Chronicles, we decided that Eileen and I could talk about situations that help medical staff professionals, number one, because we can talk about cases that have been adjudicated or public finding records.
00:13:38
Speaker
So they're not actually providers that we've credentialed. They're all public records. So nobody can ever say you guys were out here giving confidential information. And then with that case or that episode that we're talking about, we try to break it down into how does this help medical staff professionals?
00:13:54
Speaker
How does this help providers? Because if a provider gets caught up in something, has to disclose something, how do they go about that? That's a very sensitive topic. And then on the other hand, and the most important hand, how do patients protect themselves?
00:14:08
Speaker
And you see the doctor coming out of Columbia University that the university has had to pay $750 million dollars because of what he's done to female patients. We literally are covering that on episode nine coming up this week about how he did this and what he did. And Eileen really just throws out all the tea, all the gossip on that case.
00:14:28
Speaker
And then, but again, we wrap it up at the end on how we can really help. Yeah. And the thing is, if you go even just through our first few episodes that we've done, one of the examples is like drinking while intoxicated. We highlight the example of, look, there's a doctor who didn't survive getting a In other words, it was like it was life ending, ending anyway, changing.
00:14:52
Speaker
And then you have a doctor who did all the hoops. And so we go through all these hoops that she had to do in order to go back into a doctor in good stand. And then we give you an example of a current case of a doctor who just got arrested. This is everything she had to do.
00:15:08
Speaker
And the doctor was arrested at six and she was at work at 830. You can't make that stuff up. Wow. and Yeah. ah so this is the kind of stuff we want to talk about. But most importantly, we want to bring awareness to the fact when you walk into an emergency room, when you walk into a surgery center, you feel confident that the doctor you're going to see, the doctor that has a white coat on or scrubs is really qualified to do what they say. And there's a group of people out here that have been trained and studied and get certifications to make sure that we're doing this according to
00:15:46
Speaker
all the regulations, all the federal regulations, all the state regulations and the accrediting bodies to make sure that you as a patient are safe. So we wanted to create safe space to gossip about it, make it fun, but also make it interesting and learn. And hopefully the public learns something and we get everyone engaged into this beautiful, most amazing thing called credentialing.
00:16:13
Speaker
Exactly.
Patient's Role in Verifying Credentials
00:16:14
Speaker
I love it. So putting my patient hat on, if I do know I'm going to have surgery in a few weeks, is Google my one and only friend here or what other services do I have to make sure the doctor is credentialed?
00:16:30
Speaker
Great question. Number one, whatever state you're in, you're able to go to that medical board and actually look up your doctor. And so number one, you want to go there and make sure that your doctor, it's a simple name search. You don't need a lot of information and you can see, does your doctor have current board actions, passport actions?
00:16:47
Speaker
Again, not all medical boards play by the same reporting statutes, but it's a good start. The other thing, go ahead, Nailene, what else do we talk about on the show? You're the one who showed me, which I didn't know about this. So talk to her about the Google alert, because I think that's the coolest s thing ever.
00:17:03
Speaker
Yeah, that's the other thing is the Google alert. You go in there, any doctor that you're seeing, you want a Google alert, the practice name, the the doctor. And if he is or she is found it in a DUI and it does come out and they have the body cam footage of your doctor taking a sobriety test, you'll be able to see that because that'll come out on YouTube and you'll get that Google alert.
00:17:23
Speaker
Hey, and I'm just saying arrest records are completely public. If you go to your county, if you go to your county and you type in a name, it'll come up their arrest records.
00:17:33
Speaker
So you can definitely search that. The other thing is too, is don't go by the first page in Google. So there's a doctor right now that if you Google him,
00:17:44
Speaker
First page of Google has everything positive, all of the, oh, he's a wonderful doctor. And when you get to page two, you find out, o there's actually like 19 open lawsuits against this person.
00:17:56
Speaker
So there's it's really interesting that you can do that. And just remember, these are public and you can get any case that's settled and it's public. You have the Freedom of Information Act or whatever. You can get anything that you
Ensuring Safety with Credentialing Practices
00:18:11
Speaker
want.
00:18:11
Speaker
I think, Erica, I'd like to add really quick. is about plastic surgeries. are You all make sure you go out there and check their board, like not the medical board, but their board certification. That is a free verification. And you want a board certified plastic surgeon, not these run by the night doctors that are you're seeing are killing people out there right now, literally currently.
00:18:34
Speaker
Yes. Yes. Plastic surgery. fire it's It's crazy. Plastic surgery gone wrong. yeah Well, when you go down the rabbit hole, Erica, it is Alice in Wonderland and you are just taken aback by all the information out there. It's crazy.
00:18:49
Speaker
Yeah, I can imagine. All right. We do this every week with our guests. What is one thing our listeners can do this week to improve their surgery centers?
00:19:01
Speaker
Love your nurses that take care of you. Bring in something to your surgery center after you had surgery and you don't remember what happened.
00:19:12
Speaker
Just know that they took really good care of you. So go say thank you to the nurses and the team that took care of you.
00:19:20
Speaker
And I would say, you y'all ain't gonna like my answer. I would say to do a random audit on your credentialing file. Amen, sister. Okay, I'll double that one.
00:19:31
Speaker
And do a random audit on your monitoring program. And i know that seems crazy and I know it's like, what? Who wants to do extra work? But when you're really looking at it from an auditor perspective and from wanting to keep, ensure that your compliance is up to date and that you're on point, that is the best thing that you could do for your surgery center is to ensure that there are no credentialing issues.
00:19:53
Speaker
And that if anybody comes in there to look over your items, that they see that you take care of this department, as well as you're taking care of the surgery and the, all the things that are done in the OR. Perfect.
00:20:06
Speaker
I love it. Thank you both so much for coming on today. I really appreciate it. Definitely.
Conclusion & Call for Engagement
00:20:12
Speaker
Thank you for having
00:20:18
Speaker
HST Pathways recently released 12 benchmarking reports, with each report taking a deep dive into one single specialty at a time, comparing data from 2023 to 2024.
00:20:29
Speaker
Using our own unique data set from our clients, we were able to extract data points so that anyone in the industry could compare themselves to their peers. Two quick disclaimers, we only pulled data from clients who gave us permission, and we omitted any extreme outliers.
00:20:43
Speaker
So today, we're focusing on cardiovascular ASCs. And this data represents 9,179 unique cases across cardiovascular here's a quick summary of the ten metrics we looked at The first was OR block utilization.
00:21:01
Speaker
So utilization jumped from 27% in 2023 to 32% in 2024, which is a major gain. But even with that improvement, there's still lots of room to grow.
00:21:14
Speaker
Many top performing centers considered 70% utilization to be there the ideal benchmark that they hit. While the numbers we're currently seeing are obviously significantly lower than that, it does make sense considering this is a newer specialty and physicians, payers, and patients are all still getting comfortable with doing these procedures in an outpatient environment.
00:21:36
Speaker
On the flip side, though, pre-authorization rates dipped from 26% down to 21%. That's concerning since missing authorizations can delay or even cancel cases.
00:21:47
Speaker
And it's a reminder that ASCs always need to verify and use integrated payer tools, which can help streamline this process and reduce denials. Another metric that we looked at was insurance verification.
00:22:01
Speaker
So surprisingly, cardiovascular ASCs are outperforming the industry here significantly, boasting a 92% insurance verification rate versus a 78% industry average.
00:22:14
Speaker
So that obviously means fewer financial surprises and fewer last minute cancellations. And really automation here is the key. So many centers are verifying coverage when the case is accepted, again, the morning of surgery, and then at the beginning of every month to catch lapses as well.
00:22:31
Speaker
So this is really cool to see this 92% insurance verification rate. And I'm excited to look at next year's numbers to see if we could even get higher than that. And while we're mentioning cancellations, those are improving too.
00:22:45
Speaker
The cancellation rate drops slightly from 21.4% to 20.6%.
00:22:51
Speaker
Obviously, that's very small, but we'll take it and It's a very encouraging shift. Patient decision is still the top reason, making up 44% of cancellations followed by reschedules.
00:23:04
Speaker
So patient cancellations, to obviously to some degree, are very much so out of our control. But there are things we can do, especially in this case. I wonder if there was like a sub-reason under patient cancellations, if it was concerns like safety concerns, financial concerns, whatever it might be, because some of those patient cancellations maybe can be mitigated simply by more patient education or more communication.
00:23:26
Speaker
Again, some cancellations are inevitable, but others like missing labs or scheduling conflicts can be avoided with better systems and proactive communication. One pain point, though, was patient deposit collection rates.
00:23:40
Speaker
So those took a hit from 2023 to 2024, falling from 75% to 66%. That is a major revenue leak. So collecting patient deposits is hard, no doubt about it, but you can make it easy for patients to understand what they owe by texting and emailing very simple, straightforward estimates to them.
00:24:00
Speaker
You can also offer convenient ways to pay ahead of time, ideally one to two weeks before the procedure. All of that just builds trust. It helps avoid day of cancellations. All right, let's talk billing. So one of the biggest efficiency wins in the cardiovascular data that we saw was days to bill.
00:24:17
Speaker
So days to bill dropped from 11 days post data service in 2023 to eight days in 2024. That's a huge deal. ah Faster billing just means faster reimbursement.
00:24:28
Speaker
And this could potentially mean we're just seeing like a cleaner integration between EHR and billing systems and maybe just a more disciplined approach to coding and charge entry. And that brings us to claim denials. So another win here, denial rates dropped from 18% to 15%.
00:24:46
Speaker
So still not perfect, but definitely trending in the right direction. Centers that track denial patterns and address them quickly are the ones getting paid faster and more consistently. So we really want to keep a close eye on these denial rates.
00:24:59
Speaker
Are there any trends? Why are things getting denied? Is it specific payers? Is it physicians? Is it procedures? And really the more you can hone in on that, the more improvement we can see here.
00:25:09
Speaker
I do think with cardiovascular being an emerging specialty, There's going to be a lot of pushback and a lot of red tape. And these payers are going to make this as as difficult as they can, unfortunately.
00:25:20
Speaker
So I think you really just got to keep a close eye on all of these metrics, but especially around like prior auth requirements, insurance verification, claim denials, all of that good stuff.
00:25:32
Speaker
And then on the revenue side, net revenue per case did dip slightly from $4,849 in 2023 to $4,733 in 2024.
00:25:45
Speaker
So definitely not a massive drop, but just one worth watching. Ongoing financial reviews and strong reporting tools can help keep this metric steady or even push it upward and just help you identify and fix these revenue leaks.
00:25:57
Speaker
Now, even with that slight dip though, cardiovascular procedures when it comes to net revenue per case are still the second highest. So I think it's only total joints that is ahead of cardiovascular.
00:26:09
Speaker
So while we hate to see a dip overall in the big picture of all specialties, this is still significantly higher than the majority. And finally, case volume held steady.
00:26:21
Speaker
So cardiovascular ASCs are averaging 20 cases per month, which is consistent with 2023. Stability is great, but leaders should keep an eye on growth opportunities, especially as demand continues to rise in this specialty.
00:26:36
Speaker
So there you have it, 10 key data points that should help paint the picture of how this emerging specialty is performing. I know I flew through that pretty quickly. So if you're interested in more data points and use cases or just want to follow along, head to our website, go to the resources dropdown and choose either data benchmarks by specialty or state of the industry report to get your hands on even more data.
00:27:00
Speaker
And as always, I'll include all the links directly in the podcast episode notes so you can easily find them. And that officially wraps up this week's podcast. Thank you, as always, for spending a few minutes of your week with us.
00:27:12
Speaker
Make sure to subscribe or leave a review on whichever platform you're listening from. ah hope you have a great day and we will see you again next week.