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Pennsylvania’s Physician Credentialing Process Is Keeping Doctors from Patients

September 18, 2015 | By: Michael Consuelos, MD

Pennsylvania’s Physician Credentialing Process Is Keeping Doctors from Patients

Physician credentialing. It sounds like one of those down-in-the-weeds but necessary details that patients, the general public, and their elected representatives have no need to concern themselves with. Right?

Wrong. Pennsylvania’s antiquated, cumbersome, paper-based system of making sure that doctors are approved, or credentialed, to care for patients is gumming up the works. Our credentialing system is slowing down access to health care.

Rural and urban areas with vulnerable communities, where physicians can be in short supply, often feel the impact most keenly. The credentialing process can mean the difference between getting a doctor’s appointment in a few weeks—or waiting for months.

Before “new” doctors (those who have just completed their training) or doctors who are relocating can start seeing patients, they must be credentialed. That can take up to six months and involve 25–50 pages of faxed-in forms.

To slow things down even more, doctors must be credentialed not once, but separately for every insurer accepted by their practice. A typical physician practice may accept health plans for six, seven, or even more insurers.

For doctors, that’s a lot of redundant paperwork and lost revenue. For patients, it’s a big delay before they can see that new physician just hired to reduce wait times for appointments.

Credentialing bottlenecks have affected me many times during my career. In July, my wife's practice hired a new pediatrician who is still waiting to be credentialed. This lag reduces patient access and creates unnecessary administrative burden on her office.

To understand just how frustrating this can be, let’s use an example of a “credentialed” activity we are all familiar with: driving.

As a driver, what if you had to stop and apply for a new license every time you crossed state lines? Or switched car insurance companies?

In essence, that’s what doctors have to do.

Several trends are escalating this situation from major inconvenience to important policy issue.

Over the last year, nearly 400,000 Pennsylvanians—many of them previously uninsured—got health coverage through Obamacare. That’s a lot of Pennsylvanians who need to start seeing doctors.

The demand for doctors is also increasing because our state is aging. Between 2010 and 2020 about 500,000 Pennsylvanians will turn 65. This growing population of seniors and elderly will need physicians’ help to maintain the best possible quality of life and independence.

Health care champions like State Rep. Matt Baker (R-Wellsboro) aim to address this problem. Rep. Baker is working on legislation that would simplify and streamline the credentialing process. A key goal is to create a common credentialing form that all insures could use—a “common app” for physicians.

Physicians want off the sidelines and into the game. We need them in the lineup to win the ultimate prize: good health for all Pennsylvanians.

Michael Consuelos

Michael Consuelos, MD MBA, is HAP’s senior vice president of clinical integration. Michael supports member organizations in their quality and patient safety collaboratives, and physician leader engagement in clinical integration, value-based purchasing, and progress towards population health management.




Comments

Comments posted are subject to HAP’s Community Guidelines under its Terms and Conditions.

By Gustavo Camarano, MD   |   Thursday, September 24, 2015 5:56 AM

Although the process is not exactly free of flaws, if the physician has his/her profile with FCVS, it does not take that long. In my personal case tool a little bit over a month. A possible solution is to implement a US medical license under the auspices of the Federation of State Medical Boards, with support of the National Practitioners Data Bank and FDA. It is doable if the States are willing to relinquish the "power" over the credentialing process.



By Jennifer Chrin   |   Monday, October 5, 2015 12:55 PM

Speaking as an enrollment specialist, I first want to say that the paperwork has improved dramatically over the past several years. We do have a standardized application process known as CAQH that allows us to input all the necessary data to credential a provider that nearly every carrier utilizes.
While this system has lowered the amount of paperwork for enrollment it has done nothing to help with turn-around time. The worst offenders in turn-around time are the Medicaid HMO carriers. For most of these carriers it take over 1 year for the physician to be enrolled and in an area that is densely populated with these insurances not seeing those patients is simply not an option.
The carriers have all the necessary information they just take their time getting them enrolled an example of this is I had a pediatric oncologist join us in August 2014. We are now in September 2015 and he just received enrollment in one of these Medicaid HMO's, and the delay in enrollment would not be an issue if they back dated it to when it was submitted but they do not. They utilize the date they complete it so in these cases, all the patients that the provider did see are lost revenue that we cannot collect on.
Carriers need to be held to a time standard. For many of these Medicaid HMO carriers they say it takes 6 months for them to be enrolled however, they never meet those time frames often they surpass them by several months and when we ask about it they, say there is nothing they can do about it. We have has these carriers loose paperwork and delay enrollment. It should not take more than 60 days to complete enrollment for a provider. Patients and providers suffer the most when it comes to these delays. Without payment the office cannot run and if the office closes the patients have nowhere to go. We need to have a standardized turn-around time for enrollment that does back date to when the application was sent in so if there is a delay patients can be seen and the physician can be paid.
We have also experienced extreme delays when credentialing mental health therapists into Health Choices. The State requires applications be submitted through Health Choices, who in turn, review the applications and forwards on for the State approval and assignment of a Medicaid identification number. Once that Medicaid ID number is assigned, the local Health Choices carrier can then enroll the provider into Health Choices. The State application process has been lengthy, with multiple delays experienced due the clarity of requirements relayed from the State to the local Health Choice carrier. A more streamline process, would be beneficial for both the providers, as well as the Health Choice carriers as they work diligently to have providers credentialed in a timely fashion. The need for credentialed behavioral health therapists in the Health Choice organizations is very high.
I would not want to work for 6 months only to find out that they will only start paying me on month 7 so why are we asking our physicians to do the same?



By Michael Consuelos, MD   |   Monday, October 5, 2015 4:03 PM

Thank you for the insightful comments on this issue. The comments and personal experiences that you have shared address why this issue is a priority for HAP.

I encourage others with thoughts, concerns, or personal stories related this topic to please share. Your comments are helpful and appreciated.



By Michael Consuelos, MD   |   Monday, October 5, 2015 4:15 PM

Additionally, I'd like to share that the Pennsylvania Department of Human Services (DHS) has issued a memo that addresses some concerns related to Medicaid managed care organization (MCO) credentialing.

See here: http://www.dhs.state.pa.us/cs/groups/webcontent/documents/document/c_197647.pdf

DHS will require (effective January 1, 2016) MCOs to process applications within 60 days. If Medicaid MCOs do not comply, HAP can follow up with DHS monitoring staff.



By Lin Bonam   |   Thursday, November 12, 2015 2:46 PM

I agree with Jennifer's comments. I have been an enrollment consultant for 10 years. I work with multiple Medicaid HMO's in PA. I am told that they cannot even begin the credentialing process until a provider has been approved with PA Medicaid (Promise). I've had applications in process with Medicaid for 4+ months. Once I get an approval, the HMO applications are then submitted and the HMO credentialing process begins. It is taking a year or more for the provider to be enrolled with the HMO plans, and it's true, that they do not backdate the effective dates - it's the date the file goes to committee. It takes 1-3 days to complete applications and send them into the insurance companies - it takes many months for the companies to approve them. I think that this is where the problem lies. Not with the application process itself, but with the turn around time at the insurance company level. CAQH streamlines the process well.



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