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Credentialing is a big pain for doctors

physiciansWe all know how hard it is to recruit a physician these days. No matter the specialty, finding a compatible physician with the right skills is a major challenge.

There’s more on this particular subject coming soon from me in the February 2016 issue of the Pennsylvania Physician magazine, but let’s just assume you’ve overcome all those challenges and actually managed to sign a contract.

Let’s put the physician to work! Right?

Sure, you can see patients, but there’s a major problem: Getting paid for that.

Oh, you did want to get paid, right? So what do you need to do?

Insurers have to credential you – that’s each and every insurer for each patient you see. As a family doc, my practice had contracts with something like 50 or more different insurers.

Realistically, there are probably only two or three that dominate the market where you work, and they’re the important ones. But each and every insurer has to go through this process. It’s very similar. They have to confirm your identity, your credentials and skills.

You’ve hired the physician, and they submitted their credentials (which by the way, is a tremendously laborious and repetitive process), and now it sits in the insurer’s hands. Your start date comes and goes, and you either can’t see that insurer’s patients, or you are welcome to see them but you won’t get paid by the insurer, because until you are credentialed you are not in their network.

Depending on their rules, the patient may get stuck paying more (because you’re out of network), or you may have seen that patient for free, because they don’t pay at all for physicians not credentialed yet. If there were reasonable timeframes for credentialing to be done, that might even be survivable, but months and months and months can go by.

Thirty days seem reasonable, right? I mean, if you sign a contract with a start date 30 days after you accept the job offer, it’s not bad if you can get all your credentialing done before you actually start work.

But what if you start in less than 30 days (not all that unusual), or the contract starts, and you don’t have approval from the insurer yet?

And you wait and wait and wait. Your choice is to not see patients from that insurer, or see them and hope that the insurer has retroactive payment in place (very few do). But some don’t.

PAMED supports legislation (HB 1663) to streamline the physician credentialing process and make it more uniform across all insurers. PAMED is also working closely with the Department of Human Services (DHS) to ensure timelier credentialing of physicians within the state’s Medicaid program.

After discussions led by PAMED, DHS announced that, beginning in 2016, Physical Health Managed Care Organizations will be required to begin the credentialing process upon receipt of a provider’s application and must complete the process within 30 days. Learn more about PAMED’s efforts at www.pamedsoc.org/credentialing.

Some insurers are accused of delaying the process to basically get free service. It’s an economic burden added to a practice or a physician starting a practice. It doesn’t seem fair.

Trying to get something done to make it better is another issue. It’s tough enough to recruit and hire a physician. It shouldn’t be that tough to start being paid by an insurer.

By Gus Geraci, MD

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Gus Geraci, MD, is consulting chief medical officer for the Pennsylvania Medical Society.

2 comments

  1. The average healthcare provider contracts with anywhere from 18 to 30 payors, and the appropriate applications or forms need to be requested, credentialing information needs to be gathered, the applications–which can stretch as long as 50 or more pages–need to be filled out by hand, the signed paperwork needs to be submitted, followed up on, then continually kept up with in terms of updating and re-­attesting, indeed this is a huge pain.

    Med Advantage Provider Enrollment Services is an alternative. Quickly and easily submit your credentialing documentation to Med Advantage only once, and we’ll keep it on file to enroll you in the networks of your choosing.

    Acting as an advocate and liaison between your providers and the payors you have chosen, our experts will see the process through from the application request until you or the provider(s) in your office are participating in a network and receiving reimbursements.

    Our Provider Enrollment Services are designed to be an affordable outsourcing solution to meet the needs of individual providers, as well as larger facilities. If your practice consists of one provider or hundreds, you’re a start-up clinic or you’ve been in business for years, our service plans are tailor-­made to fit your unique needs.

  2. Although I’m now retired, I can relate to the headache of credentialling. Between the hospitals, M’care and M’caid, and numerous insurers, the DEA and State Pharmacy laws, each with their own cycle of such activity and hassle, and expense, it seemed that every 2-3 weeks, I’d get a reminder to renew with someone, and each time, I’d be filling out a NEW application, from scratch, as though I’d just come into the system for the first time. “They” are unable to fill in much of the standard stuff from the last app, and ask for updates/corrections.
    It seemed to be snow-balling into more hassle every year and was at least a part of my timing on the decision to retire.
    Glad to be done with it.

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