Credentialing Are We There Yet? By: Kelly Mattingly

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1 Credentialing Are We There Yet? By: Kelly Mattingly How many of you, that understand what its like to be in a car with a five year old, remember those long road trips, where every five to ten minutes you would get a poke on the side, and that question came Are we there yet? Their demeanor is very kind, yet it is clear they are ready for the trip to be over. Maybe that s not your child. Maybe your child was the screamer ARE WE THERE YET? * [Insert grunting noises]* Or better yet, maybe your child was the one that sat quietly and never asked the inevitable question repeatedly, the one that never made the trip move along any more expeditious. He or she just sat there and enjoyed the music, the farm animals by the side of the road, or kept occupied with a portable DVD player almost forgetting that there was a destination you were trying to reach. Then at the very end of the trip that child says Well, it was about time we arrived. I had to go potty forever ago. - As the parents were supposed to know! As a credentialing professional, I can relate to these types of children in a different context, in the urgent care world. There are three main types of urgent care business owners. The laid back, yet uninvolved owner: This owner is initially pleasant when reachable. They expect others (consultants and other third parties) to take care of the tasks and duties they don t understand. When the walls start crumbling down, because of a lack of communication, this type of owner takes little or no responsibility for their complete disconnect or disinterest in the credentialing process and they are quick to blame others. After all, that s what they paid consultant to do - to take care of it all! The Type A owner: This owner typically has the attitude that they can do it all (what they sought out a consultant to do) themselves and spend a lot of time telling consultants that they, themselves, can do a better job than the service the consultant or third party is providing. This may be true. There are some quite cognizant providers in this industry that really do understand credentialing. However, this type of provider is typically intimidating and ample energy is usually spent with non-productive conversations and egoism. At times the Type A owner will muck up the credentialing process by getting involved directly with the insurance companies (typically because the process is not moving along fast enough for them), therefore creating barriers between the payor and the consultant. Relationships typically need to be mended between the insurance company and the consultant or third party when working with this type of owner. Remember, consultants are working with the insurance companies repeatedly, and usually with the same contact person, therefore the urgent care business owner benefits from that already formed relationship. Type A owners can sometimes damage those relationships. The involved and receptive owner: This type of owner is typically a good listener. After all, there is a reason they sought out someone else to handle credentialing for them. They don t have the time and frankly their business is medicine, not paperwork. They understand the importance of letting go just enough to free themselves up to handle other important business details (like treating patients, handling patient complaints, etc) relieving themselves of the burden of credentialing. They are also hasty to respond to your requests, such as updated licenses, medical malpractice, and signature pages, as they understand the financial implications of failing to get the credentialing paperwork completed and submitted in a timely manner. They act more similar to a business partner.

2 Moving on, and back to my point, all of these owner types eventually ask the question, some more frequent than others, Are we there yet? Or rather, Am I and/or my providers or staff participating with the health plans yet? Because the majority of urgent care owners are physicians, they do not typically wholly comprehend the credentialing process, its significance, and why it takes so freakishly long to become a participating provider! Most have been employed physicians for their entire career career, either through private practice(s) or through a hospital system, and up until this point they have never been required to facilitate the credentialing process. A practice administrator or medical staff office has always taken care of business for them. Now they own and operate their own freestanding urgent care and along comes the reality check! The real deal is: Credentialing is a lengthy process and it takes forever! Not understanding the importance of credentialing can and will hinder your ability to get paid. Remember that. Become an involved and receptive owner that wants to participate and take a reasonable amount of ownership in the credentialing process, as that is a major indicator of how successful they will become. Understand the process. It is reasonable to delegate the credentialing out to a third party, but it is imperative to understand the nuts and bolts of how the credentialing process works. Understand what your consultants are doing on the paperwork side to the processes that take place on the payor end the mysterious part, otherwise known as the black hole. The keys are in the ignition. Your car is ready to go! It is first important to understand the meaning of credentialing before seeking an understanding of why it takes so long. Credentialing is a process by which either a facility s or its provider s credentials are closely verified to ensure that the facility or providers meet the quality standards of the respective health plan or payor. Credentialing is an ongoing process, as a provider s (or facility s) credentials are typically re-verified every 2 to 3 years. Credentialing is basically a process split into two major parts: The front end piece is performed by a third party credentialing specialist or internal office manager who s job is to collect information from the provider, complete the credentialing applications, and submit them to the health plans. The back end piece is performed by the health plan, whose job is to verify various elements in the provider s application, ensure the applications are forwarded to the credentialing committee for approval. The final result is a notification to the provider of the credentialing committee s decision for network participation. Sounds simple, right? There is more to the story, so read further. The third party credentialing specialist: Above was the short version of the process on the front end, which involved the collection of information, through the submission of applications. Here is the detailed response: First there is a collection process, typically, where the consultant or other third party collects all of the provider s credentials, which should mirror the requirements of the payors. The requirements typically include: Documents: State licenses State controlled Substance licenses DEA,

3 Other: Current medical malpractice certificate, past medical malpractice certificates Residency completion certificate Board certificates(s) Military discharge records Copy of passport, Copy of drivers license ECFMG certificate, etc. Date of birth Social security number Personal addresses and s Hospital affiliations Liability actions Professional references Professional associations Full disclosure of education, training, and work history Explanation of any gaps 30 days or greater, etc. If the collection applications are incomplete, credentialing is put on hold until the credentialing specialist (at the third party) can collect what they need from the provider. As a tip: office managers and business owners should be actively assisting their credentialing specialists with this process. Typically providers will respond to pressure from their boss, rather than a third party. An unresponsive provider will suspend the process for long periods of time and will contribute to a loss in revenue. Once a provider returns complete information, the consultant may enter the data into a credentialing database. This allows the credentialing specialist to rapidly populate multiple credentialing applications for various networks and health plans. A credentialing professional will then send the signature pages off to the provider for a wet signature. When the signature pages are returned to the credentialing professional, the applications are then submitted to the insurance plans or payors. You re not even half way to your destination. You are not there yet! The health plan: The health plan or payor will receive the submitted application. Someone at the payor then assigns the provider s file to a payor credentialing specialist, who will perform primary source verification on the provider s credentials based on NCQA standards and requirements. Most health plans are accredited through a national organization named NCQA (National Committee for Quality Assurance). NCQA publishes various guidelines and rules for verifying a practitioner s credentials. Very important information: NCQA allows a health plan 180 days to verify all of the required elements in a provider s credentialing file and then to respond to the provider with a decision regarding whether he/she has been approved or denied into the payor s network. NCQA allows six months of possible processing time!

4 There are few sources that NCQA considers a primary source for verifications. The health plan is limited to using these specific sources when verifying the credentials of a provider. If the health plan fails to use these approved primary sources, they could quickly lose their accreditation. Examples of primary sources include: the AMA profile, the department of professional regulation (depending on the state), the NPDB (national practitioner databank), and so on. Some of the required elements health plans are required to primary source verify include: State licenses to practice Highest level of education Sanctions Medical malpractice history Work history mostly to identify any gaps greater than 30 days Attestation and release Other elements: Health plans also reserve the right to verify elements that are above and beyond the scope of NCQA. An example: Board certification. Health plans create credentialing requirements at their own discretion. There are many snafus that can lead to lengthy application processing times. Most of these issues can be resolved through additional written explanation or just by filling out the application in its entirety. Listed are some common examples of issues that could be discovered in a credentialing file that could lead to serious processing delays: Bad references Missing or incomplete information in your application A trend of medical malpractice negligence Expired documents in your application Unexplained gaps in your education and professional experience timeline, etc. You ve made it to the home stretch, possibly 150 days later. You re still not there yet! After the primary source verifications are complete, the file must sit for committee review. These reviews traditionally take place once a month (usually the same day of the month, every month), and are approved by a select group of physicians of various specialties. The committee physicians typically have to vote for either approving the provider file, denying the provider file, or tabling the provider file for further information (to make a decision at the next committee). If the file is approved, then the practitioner is to be notified of the decision that was voted upon (per NCQA requirements). Remember, in 2-3 years this cycle will start all over again. Re-credentialing is required of the clinic and/or the providers again for maintenance purposes. Some of the initially verified credentials will not be verified, as they will never change, such as medical school, residency training, etc. The health plans will require primary source verification of items such as: maintained medical malpractice insurance, any new medical malpractice cases, CME s, etc. The next time you think about asking the question, Are we there yet, remember the fiveyear old in the back seat. The more you ask the pesky question and try to push the process, the longer the process will seem to take. Become an education urgent care owner.

5 Understand what type of owner you want to be, understand the parts of the process you can control, and also understand what you cannot control. You have made it to your final destination! Congratulations!