EPISODE DESCRIPTION

"My provider never got credentialed." Melissa Hinckley has heard that complaint for most of her career. Then she checks, and the provider has been credentialed since before she even entered healthcare. The real break is usually somewhere else, like a practitioner's NPI that was never linked to the tax ID on the contract. It still gets filed under credentialing, and so do the regulations written to fix it. Melissa started in the Harvard Pilgrim call center taking member calls and has since run provider enrollment, credentialing, network adequacy and directory work at Harvard Pilgrim, Oscar Health, Mass General Brigham Health Plan and Point32Health, with a stint in fraud investigations along the way. In this conversation with Nick Helfrich and Mitch Gorodokin, she breaks down the provider enrollment lifecycle, the one question she trains every team to ask, and why regulators, payers and providers need to get in the same room to untangle provider data.

Key takeaways