Senate Study Committee on Medicaid Managed Care Organization Credentialing

Transcription

1 Senate Study Cmmittee n Medicaid Managed Care Organizatin Credentialing Amerigrup Cmmunity Care f Gergia Wednesday August 27, 2014 Mel Lindsey, Senir Directr Gvernment Relatins Aarn Lambert, Directr Medicaid Field Operatins Amy Martinez, Directr Credentialing

2 Amerigrup Cmmunity Care f Gergia Overview Cntract with the Department f Cmmunity Health since July 2006 We are a cmmunity-fcused managed care cmpany with an emphasis n the public sectr health care market. We crdinate the members physical and behaviral health care ffering a cntinuum f educatin, access, care and utcmes resulting in lwer cst, imprved quality and better health status fr Gergians Service Area: 6 Medicaid Regins Atlanta June 2006 East/Nrth September 2006 Sutheast Octber 2006 Central & Suthwest February 2012 Member and Prvider Prfile Membership: 353,941 1 TANF & CHIP: 327,470 P4HB: 3,486 Gergia Families 360: 22,985 Prvider Prfile: 23,871 2 PCPs: 3,671 Specialists: 17,050 Hspitals: 143 Ancillaries: 1,840 1 As f August As f July

3 Credentialing Overview Why we credential Amerigrup is cmmitted t perating an effective, high-quality credentialing prgram The credentialing prcess allws us t: Ensure ur members are receiving services frm fully licensed and accredited prviders Ensure ur netwrk f prviders are held t a high quality standard Detect, avid, and prevent fraud, waste, and abuse in ur healthcare system Cntract Requirements Adherence t Natinal Standards Natinal Cmmittee Quality Assurance (NCQA) Jint Cmmissin n Accreditatin Healthcare Organizatin (JCAHO) American Accreditatin Healthcare Cmmissin/URAC Prviders are credentialed in accrdance with State law and Federal regulatins Prviders have a valid Gergia Medicaid ID Allwed 120 days t cmplete the prcess Amerigrup s credentialing prcess is rutinely audited by external parties fr cmpliance t State and Federal guidelines 3

4 Amerigrup Credentialing Prcess Prvider Requirements Only accept applicatins fr credentialing f new prviders thrugh the Cuncil fr Affrdable Quality Healthcare (CAQH) Must have an active Gergia Medicaid ID Each prspective prvider, ancillary, r hspital will cmplete the jint Medicaid and Care Management Organizatin (CMO) credentialing applicatin Centralized credentialing applicatin is nt used fr: Prviders wh currently have an active GA Medicaid ID Adding new service lcatins Re-credentialing Applicatin Check-list: Curriculum vitae Liability insurance Malpractice histry Participating agreement IPA/PPO/PHO prvider acknwledgement Practitiner attestatin Physician/practitiner credentialing applicatin and release frm Physician bard certificatin Disclsure f wnership and cntrl interest statement 4

5 Amerigrup Credentialing Prcess (1) Credentialing Applicatin Management (2) Primary Surce Verificatin (PSV) (3) Medical Directr Review Review all prvider credentialing applicatins and checks fr cmpleteness Respnsible fr assisting prviders in the applicatin prcess- answer questins, respnd t inquiries Assists prvider in btaining the CAQH ID number Slicits missing, expired r incrrect dcumentatin that has been submitted fr credentialing by the Health Plans. Outreach is made directly t the practitiner r prvider (3 attempts). Submits all applicatins t primary surce verificatin Verificatin f bard certificatin Verificatin f educatin and training Verificatin f wrk histry Verificatin f hspital admitting privileges Verificatin f state license infrmatin Verificatin f DEA number Verificatin f malpractice insurance Verificatin f past sanctins Verificatin f respnses prvided by the prviders credentialing applicatin Verificatin f the credentialing applicatins after PSV review Review and makes recmmendatin n the unclean file Reviews fr quality f care issues identified in the credentialing applicatin Every credentialing applicatin is reviewed by ur Medical Directr Lead fr the Credentialing Cmmittee 5

6 Amerigrup Credentialing Prcess Other prcess cnsideratins Each prvider has the right t inquire abut the status f his r her applicatin Each prvider has the right t review infrmatin btained frm primary verificatin surces during the credentialing prcess Amerigrup allws fr delegated credentialing assigned credentialing respnsibility t anther grup r entity The credentialing prcess invlves cmmunity based prviders t participate in ur Credentialing Cmmittee and Medical Advisry Cmmittee We credential the fllwing prvider types: Medical dctrs Dctrs f stepathy, pdiatric medicine and chirpractic Physician assistants Optmetrists Nurse practitiners Certified nurse midwives Licensed prfessinal cunselrs/scial wrkers Psychlgists Physical/ccupatinal therapists Speech/language therapists Hspitals and allied services (ancillary) prviders 6

7 Credentialing by the Numbers % f Time Allcated t Each Credentialing Task (YTD Avg.) 3% 34% (1) Credentialing Applicatin Management (2) Primary Surce Verificatin (PSV) 63% (3) MD Review 2014 % f Time Allcated t Credentialing Task January February March April May June YTD Avg. (1) Credentialing Applicatin Management 25% 39% 33% 32% 35% 37% 34% (2) Primary Surce Verificatin (PSV) 69% 58% 64% 65% 63% 58% 63% (3) MD Review 5% 3% 3% 3% 2% 5% 3% 7

8 # f applicatins 300 Credentialing by the Numbers 2014 Credentialing Applicatin Vlume January February March April May June Initial Reciepts Practitiner Initial Cred Prductin Facility Initial Cred Prductin Practitiner Recred Prductin 2014 Credentialing Applicatin Vlume January February March April May June YTD Initial Receipts Practitiner Initial Cred Prductin Facility Initial Cred Prductin Practitiner Recred Prductin Facility Recred Prductin

9 Q&A Cntact Infrmatin: Mel Lindsey: Aarn Lambert: Amy Martinez: