HEALTHCARE ENTERPRISE: ProviderTrust: Providing a Passport for Employee Compliance
HEALTHCARE ENTERPRISE:  ProviderTrust: Providing a Passport for Employee Compliance | Healthcare Reform, ACA, CMS, ProviderTrust, Kroll, XMI High Growth Development Fund, TNInvestco, Michael Rosen, Christopher Redhage

The old phrase from the Reagan administration — “trust … but verify” — has become even more prescient in this era. It could certainly describe the modern mission of ProviderTrust, LLC, a healthcare risk mitigation and technology firm based in Nashville.

Since its beginning in 2010, ProviderTrust has offered healthcare organizations, staffing agencies, physician offices and individual providers the ability to maintain, update, and continuously monitor their licensure documentation and professional credential requirements using innovative technology.

Created by local business executives Michael Rosen and Christopher Redhage, ProviderTrust offers clients greater efficiency, increased productivity and a higher level of compliance in the credentialing process.

Rosen, cofounder of Background America, which became Kroll Inc., serves as president of ProviderTrust. He observed “Today, there are millions of licensed and registered healthcare professionals in the U.S. who provide care in hospitals, long term care facilities and physicians’ offices. Too often their employers are not able to ensure that their credentials have been properly tracked and monitored. For those organizations, the penalties and fines for non-compliance are serious.”

He added, “ProviderTrust resolves this problem with a simple and efficient online solution that continually checks each provider’s license status, sanctions and restrictions, and delivers immediate alerts to the employer and licensee when there is a change.”

Rosen, a native Nashvillian, said ProviderTrust is based here because the city is a “healthcare business mecca that spawns entrepreneurship.” He added, “It seemed like a ‘natural’ to marry technology savvy with the ability to manage risk in this environment.”

ProviderTrust was the recipient of startup funds from XMI High Growth Development Fund, one of the 10 venture capital funds participating in the TNInvestco program, which is designed to  provide capital to high-growth, transformational businesses in Tennessee.

It has often been said ‘it’s not what you know; it’s who you know.’ In the current heavily regulated climate of today’s healthcare business, it would be more accurate to say ‘it is what you know about who you know — and who you employ.’

As of March 25, 2011, healthcare organizations reimbursed by CMS must conduct ongoing monitoring of all participating licensed caregivers. Pointing to the nation’s more than 10 million workers in healthcare and allied fields and more than 700,000 physicians, Rosen observed, “Most facilities are typically outsourcing employee background checks or, at most, doing an Excel spreadsheet on compliance that is passed down to a number of people. CMS found that up to 60 percent of records that do exist are typically missing almost 60 percent of the necessary information. Without active oversight, updates to an employee’s file were rarely acted upon.”

The Office of the Inspector General (OIG) is funded to pursue companies that hire an individual who has been excluded or terminated from participating in … or being reimbursed for … services involving federal healthcare programs. The Affordable Care Act (ACA) defines “exclusions” to include additional crimes and civil actions such as conviction for a crime, patient abuse or fraud. New to the category this year is the addition of failure to pay student loans and convictions involving controlled substances.

As of Jan. 1, 2011 employers must conduct a search for all state Medicaid actions to determine if a licensee has been “excluded or terminated” from other state Medicaid programs. If an employee is excluded in one state, the law now requires that employee be excluded in all states. The OIG is able to suspend future payments to an organization while investigating such payments. These fines and penalties are imposed if the company “knew or should have known” that an employee was excluded.

Recently a Nashville man was indicted by an Atlanta grand jury on charges of impersonating a physician in Georgia. According to the indictment, the impersonator persuaded numerous doctors in Nashville and Atlanta, who were unaware of his lack of qualifications, to bill Medicare, Medicaid and private insurance companies under their own provider identification numbers for the allergy-related care he provided at the doctors’ offices and health fairs. The defendant treated more than 1,000 patients and bilked $1.2 million from benefit programs.

ProviderTrust’s services not only help providers and facilities stay on top of requirements but could keep just this type of fraudulent situation from happening to their clients.

Rosen said, “We realized when we looked at the market from the period of the point of hire to the required renewal of credentials two years later, that there is not a lot of technology being put to use. We monitor and maintain license requirements and certification updates in the period between hiring and recertification for our clients on a national level. We run a check for updates every night so that every employer knows the next morning if there is missing data or the need for additional certification of any employee,” he pointed out.

“We stay in constant contact with our clients, and the system stores all information and monitors alerts for both clients and provider. Nurses and other workers can sign up for free email notification of impending certification updates or education requirements.”

Missing a deadline or being unsure about an employee’s credentials is a costly mistake. Civil fines can be up to $10,000 for each item or service furnished by a provider’s employee during the excluded period, plus fines up to three times the amount billed and exclusion from the program may be imposed. ACA allocates $110 million to be spent to enhance enforcement efforts of these regulations in 2011-12 alone.

Rosen is counting on the service ProviderTrust offers in protecting employers’ and employees’ reputations and resources to prove invaluable in an increasingly regulated environment.