March 12, 2018

There is no more frustrating aspect of the billing business than provider enrollment. When ABC client practices hire new physicians and CRNAs, they want to be able to get paid for their services as soon as they start working.  Although ABC advises clients that it can take 60 to 90 days to complete the enrollment process with all appropriate payers, even this estimate can sometimes be overly optimistic. The vagaries and idiosyncrasies of payer-provider enrollment policies can be a nightmare.  Thus far, those of us in the business have just come to assume this was a painful reality with no real solution.

Legislation recently introduced in Virginia could prove to be a light at the end of the tunnel.  A state bill would direct health plans to develop protocols for paying physicians for services performed when their credentialing applications are received instead of once all the paperwork had been received and processed.  A similar bill was proposed in Pennsylvania in 2015 and tabled, but the issue was resurrected with a new bill, introduced in 2017.  This could prove to be a hot legislative issue if enough medical groups call attention to it, which is what we urge all ABC clients to do.

Three issues have made this a major challenge for all billing companies.  First, the amount of information required keeps changing and expanding.  It is not uncommon for payers to now require copies of all relevant documents pertaining to training and certification.  They may even require an attestation that the provider has never been suspended from a public plan, such as Medicare.  Second, although there is a standard form in use, not all plans recognize it.  This essentially means that there can be separate guidelines for each plan.  Finally, in an era for budget cuts, especially for Medicaid plans, the processing times keep growing and it is not at all uncommon for applications to be completely lost, thus requiring that the process be restarted.

This issue affects every practice that hires new providers.  Someone must carefully monitor the process for each provider to ensure that no step or required document is missed, as this will impede the approval process.

A bill that would require health plans to reimburse physicians for services delivered when the credentialing process begins, rather than when it is completed, offers a glimmer of hope that a remedy, in one state at least, may be on the horizon.  Virginia House Bill 139, which would direct health plans to develop protocols for paying physicians for services performed when the credentialing application is received, won near-unanimous support from the Virginia House and passed the Senate Commerce and Labor Committee on February 26.

The legislation would require carriers to reimburse physicians for services rendered from the date at which their applications are received, at the same in-network rate they would be paid if they were already credentialed.  The law would apply only in instances in which the carrier already has a contractual relationship with the medical group or hospital.  Physicians would be required to notify patients, before providing services, that their credentialing application is pending approval.

In addition: 1) Any reimbursement paid to the physician would be retroactively recouped or rescinded if the physician’s application were denied; 2) A carrier would not be required to reimburse the physician if their application were not approved or the carrier were otherwise not willing to contract with the physician; 3) The medical group might be required to refund any reimbursement paid to the physician whose credentialing was obtained by fraud; and 4) The medical group would not be allowed to collect from a covered patient for services provided by the physician.

New York has introduced a similar bill that would give “provisional credentialing” to physicians while their applications were pending.

Pennsylvania House Bill 125, introduced in 2017, calls for a standardized process and timeline for use by insurers in making decisions regarding credentialing applications.  The bill would require all insurers in Pennsylvania to accept a standard application from the Council for Affordable Quality Healthcare (CAQH) and to issue a credentialing determination within 45 days.  (CAQH is a nonprofit alliance of leading health plans and networks established to reduce administrative requirements and costs for physicians and other healthcare providers.  The organization has developed a single, standard online form—the CAHQ application—through which providers in all 50 states and the District of Columbia are able to enter their information free of charge through an interview-style process.)

We encourage all clients to contact their state societies to inquire about existing or planned advocacy efforts in their states to shorten and simplify the credentialing process.  Without intervention, this challenge will only get worse.

We want to hear from you.  Do you have a topic you would like to see covered in an ABC eAlert? Please send your suggestions to info@anesthesiallc.com.

With best wishes,

Tony Mira
President and CEO