Improvements to Electronic Portal Streamline Enrollment and Credentialing
Economics Feature — August 2015
Tex Med. 2015;111(8):53-59.
By Amy Lynn Sorrel
Just like the drugs physicians prescribe to their patients, the Texas Medicaid program has a number of side effects that, for many doctors, make participation in the program a bitter pill to swallow.
Two of those major side effects: A slow and cumbrous enrollment process that, in turn, delays the credentials physicians need to participate in Medicaid HMOs, now that Texas Medicaid has moved almost entirely to managed care.
A new-and-improved prescription is on the way, thanks to years of advocacy by the Texas Medical Association and follow-through by the state and the health plans.
Enhancements to Medicaid's electronic enrollment portal aim to speed up the process at a critical juncture: The Affordable Care Act requires all Medicaid health professionals to reenroll in the program at least every five years. Physicians are next on the list, and anyone who enrolled before Jan. 1, 2013, must do so again by March 24, 2016. (See "Reenroll Now!")
The reenrollment requirement also applies to physician assistants and advanced practice registered nurses, psychologists, social workers, podiatrists, and chiropractors. At press time, roughly 98,000 Medicaid professionals had yet to reenroll, according to the Texas Health and Human Services Commission (HHSC).
Launched in April, the online portal upgrades also coincide with a statewide effort to centralize the credentialing process among Medicaid HMOs — an idea spurred on by Medicaid reform legislation TMA backed in 2013 and carried out in another package of medicine-friendly Medicaid bills won in 2015. (See "Medicaid in the Legislature.")
For Austin pediatric cardiologist Hanoch Patt, MD, the changes mean he will no longer have to step away from caring for patients to sign paper documents and mail them to HHSC to complete the enrollment process he starts online. "It didn't make sense," the member of TMA's Select Committee on Medicaid, CHIP (Children's Health Insurance Program), and the Uninsured, said.
Dr. Patt says it can take two months for HHSC to confirm his practice is reenrolled. Meanwhile, health plans wait on confirmation before they can recredential the physicians to remain active in their networks, allowing physicians to continue seeing patients and getting paid for their services — a process Dr. Patt says can take another month or two. If his practice hires a new physician, "you're talking almost half a year before you're ready to go."
"This has been a long time coming, at least since the beginning of managed Medicaid [in 2012]. I don't think HHSC was aware initially of the slowdown in these processes, and it took some time, but they now understand the challenges from our standpoint," Dr. Patt said. "It's difficult enough to take care of these very vulnerable patients who need good health care, so any kind of streamlining that decreases our cost of providing needed care for these patients is significant."
That's especially true, he adds, after the 2015 Texas Legislature ultimately nixed a plan to continue paying select primary care physicians at rates that match Medicare per ACA. Despite the House's advancement of the measure, the plan dissipated in the final weeks of the session in favor of shifting the funds into sweeping tax cuts. ACA increased Medicaid primary care payments to Medicare rates for 2013 and 2014 using federal funds, but the pay bump expired Dec. 31, 2014.
"It's important to recognize that streamlining all of these Medicaid administrative processes is great. But it's a small piece of a very big puzzle," Dr. Patt said. "It's so economically challenging to take care of these patients, and we had the opportunity to be proactive this session on a primary issue affecting Medicaid. We almost made it. But it's extremely disappointing to see that work undone."
Enrollment Made Easy
HHSC has slowly but surely chipped away at the administrative red tape.
"The legislature spoke loud and clear, and we want providers to participate in the managed care system," said Gary Jessee, deputy director for HHSC's Medicaid and CHIP division. "Anything we can do, we want to do: enrollment, claims, credentialing, prior authorization. We are working through a number of those areas to try to improve the provider experience."
When it comes to enrollment, HHSC Director of Claims Administration and Operations Management K.J. Scheib says, "We heard providers saying the [electronic] system is clunky and difficult to get through, and these are big changes to the system we've made." The improvements do not do away with the option for paper applications. "But the hope is with the enhancements, [physicians] will choose to submit electronically," which has its advantages, she added.
The upgrades apply to applications submitted through the TMHP website on or after April 26, 2015.
Physicians will notice some of the up-front changes immediately. Most of them will expedite reenrollment simply by reducing the need for printing and mailing documents, like proof of licensure, Ms. Scheib notes. Among the changes:
- System updates that make the portal compatible with more recent Internet browsers;
- The ability to immediately upload supporting documentation;
- An e-sign feature that allows physicians to sign the enrollment agreement electronically;
- Instructions on how to upload documents and submit the application using an e-signature; and
- Guidance and more accurate error messages to avoid application mistakes before submission.
Physicians newly enrolling in Medicaid can use the portal, too. But for those already enrolled, the system will pre-populate the application with physicians' demographic data on file: name, address, specialty, and license registration numbers.
Other back-end upgrades might not be as visible, Ms. Scheib explains, but will cut down on the back-and-forth for paper applications HHSC representatives enter into the electronic system.
Previously, physicians submitting a paper application would receive a separate letter in the mail for each mistake found — a Social Security number that doesn't match, for instance. Five errors meant five letters. With the new system, however, a single letter will list all of the corrections needed at once.
The ACA requirement for Medicaid reenrollment was a large impetus for the changes, Ms. Scheib says. The March 24, 2016, deadline applies to physicians participating in traditional fee-for-service Medicaid and managed care.
The changes also follow HHSC's transition last summer to a new Medicaid claims administrator after the state sued the former Medicaid contractor, Xerox, for fraud-related charges. With the switch to Accenture in August 2014, TMA officials say HHSC identified a number of problems that created unnecessary administrative burdens for physicians, including enrollment and prior authorization delays, and the agency has since worked with Accenture to improve.
One-Stop Credentialing Shop
HHSC officials say the enrollment upgrades on their end also will go a long way to help clear up credentialing crunches on Medicaid HMOs' end so they can maintain their networks. The agency is notifying health plans of physicians' reenrollment status so HMOs can help with outreach, as well. "We want to make sure the networks are robust," Ms. Scheib said.
In addition, the 2015 legislature passed TMA-backed Senate Bill 760 by Sen. Charles Schwertner, MD (R-Georgetown), which strengthens existing state requirements for expedited credentialing as part of an overall plan to beef up Medicaid HMO network adequacy. The bill — which at press time still awaited Gov. Greg Abbott's signature — increases oversight and accountability of Medicaid HMOs' network adequacy by, among other provisions, raising current Medicaid access criteria and suspending enrollment in health plans if they fail to maintain adequate networks.
Meanwhile, plans afoot to create a one-stop data repository for credentialing purposes could go even further to alleviate access-to-care delays by making it easier for physicians to participate in those networks.
"I have one provider who needs to be in network, and I have to hold claims up" because of lags in enrollment processing, says Mary Dale Peterson, MD. She is president and chief executive officer of Driscoll Children's Health Plan in Corpus Christi and a member of TMA's Select Committee on Medicaid, CHIP, and the Uninsured. "It creates complications for health plans and for doctors. I'm not allowed, based on state rules, to pay until I get their [Medicaid enrollment] number."
Medicaid HMOs also must follow various rules and quality standards set up by the Texas Department of Insurance and health plan accrediting bodies that require background checks to verify physicians' professional qualifications: everything from education, training, and licensure to liability coverage, claims history, and hospital privileges.
"We take that seriously, and of course, having the right network of doctors is really critical," Dr. Peterson said. "We don't want to give that up. But we're looking at ways to make it easier for everybody."
One option: Instead of physicians filing the same information again with each Medicaid HMO — there are at least 20 in Texas — and health plans processing duplicative paperwork, all parties seem to align over the potential for a centralized, statewide credentialing verification organization. Physicians would go to one place to submit their information; health plans would go to the same place to retrieve what they need to complete their credentialing processes.
The idea, while not new, finally gained traction after the 2013 Texas Legislature passed Senate Bill 1150, calling on HHSC to develop a plan specifically to reduce such administrative burdens on physicians and other health professionals participating in Medicaid managed care. SB 1150 established a multistakeholder workgroup physicians, health plans, and others who put the credentialing repository on their wish list.
Former Texas Medicaid director and health care consultant Billy Millwee heads up the project, initiated by the Texas Association of Health Plans (TAHP). He says the organization shares physicians' desire to make Medicaid less administratively complex and sought a private market solution to create a common credentialing platform. The Texas Hospital Association (THA) has joined forces with TAHP to explore a similar option for hospital credentialing.
"I'm optimistic this is going to go a long way to really reduce the hassle providers face in Medicaid, given the creative thought put into a private sector response," Mr. Millwee said.
TAHP and THA are still researching and developing the platform but look to Arizona for precedent. That state mandates that all Medicaid managed care plans participate in a centralized credentialing hub "because they felt so strongly about simplification," Mr. Millwee said. The Arizona Association of Health Plans Credentialing Alliance launched in late 2013. Georgia is following suit.
In Texas, as part of the sunset review process — which the legislature uses to regularly evaluate the performance of state agencies — an extensive bill to overhaul HHSC, Senate Bill 200, requires the agency to streamline Medicaid enrollment and credentialing processes by Sept. 1, 2016. SB 200 specifically authorizes HHSC to designate a centralized credentialing entity and require Medicaid HMOs to use it. Gov. Greg Abbott signed that bill into law on June 17.
Mr. Millwee anticipates the project will be up and running within the legislature's prescribed time frame. While the first rollout would encompass Medicaid plans, it could ultimately expand to include commercial insurers, as well.
Now that HHSC has initiated improvements on the enrollment side, "we are looking into creating an interface between the statewide credentialing organization and the enrollment file," he added. "It will certainly make this project work better, so we want to be in lockstep with HHSC on this."
Next steps also would include a series of workgroups among health plans to standardize certain credentialing elements.
Dr. Peterson clarifies, however, that having a single repository does not translate to automatic approval by health plans, which must still screen physicians' qualifications through their credentialing committees. "It doesn't negate that. But it would hopefully give everyone one place to go, instead of having paperwork all over the place."
Driscoll is one of several health plans doing that to some degree now, by choosing to pay a common vendor to gather physician credentials. Physicians can submit the information free of charge. The problem, says Dr. Peterson, is the information is not always up to date.
In the meantime, Mr. Jessee says HHSC also communicates to Medicaid HMOs that nothing prevents them from starting the credentialing process while they wait on enrollment confirmation from Texas Medicaid.
Some plans already do so, but TMA is urging HHSC to adopt the approach as a best practice for all Medicaid HMOs to expedite physician credentialing, in addition to the protections created under SB 760.
"There are a lot of good things going on," Mr. Jessee said. "This is a big deal."
Amy Lynn Sorrel can be reached by phone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.
Did you enroll in Texas Medicaid before Jan. 1, 2013? If so, you must reenroll by March 24, 2016, to maintain your participation in traditional fee-for-service Medicaid and Medicaid managed care networks. Federal law requires all Medicaid physicians and health professionals to reenroll every three to five years. To be considered fully reenrolled, physicians must:
- Submit a completed reenrollment application; and
- Receive notification from Texas Medicaid & Healthcare Partnership (TMHP) that the application has been approved.
To make the reenrollment process easier, Texas Medicaid has implemented numerous improvements to its electronic enrollment portal, including the ability to upload supporting documents and electronically sign the reenrollment form.
To allow sufficient time for processing, Texas Health and Human Services Commission officials recommend physicians start working on their applications immediately. The process takes 45 days on average. For additional information and assistance:
Medicaid in the Legislature
While there's more work to be done, the 2015 Texas Legislature again responded to TMA's call for simplification and protections in the Medicaid program. Among them:
- Senate Bill 207 by Sen. Juan "Chuy" Hinojosa (D-McAllen) outlines clear criteria for Medicaid fraud investigations by the Office of Inspector General, including clarifications that fraud does not include unintentional technical, clerical, or administrative errors.
- Senate Bill 760 by Sen. Charles Schwertner, MD (R-Georgetown), increases oversight and accountability of Medicaid HMOs' network adequacy by, among other provisions, raising current Medicaid access criteria and suspending enrollment in health plans if they fail to maintain adequate networks.
- Senate Bill 200 by Sen. Jane Nelson (R-Flower Mound) reorganizes the Texas Health and Human Services Commission and provides for a host of simplifications to Medicaid managed care, including streamlined enrollment and credentialing processes.
- House Bill 839 by Rep. Elliott Naishtat (D-Austin) ensures children have continued health care coverage when released from a correctional facility by eliminating rules that cut off juveniles' eligibility for Medicaid when they enter a detention facility.
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