TMA Practice Consulting Eases Pain of Credentialing

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Practice Management Feature - March 2010  


Tex Med. 2010;106(3):31-36.  

By  Crystal Conde
Associate Editor  

Christopher Curzon, DO, was fresh out of fellowship training at Duke University and eagerly anticipating joining a cardiology practice in San Antonio in the summer of 2008. However, the pediatric cardiologist couldn't participate fully in outpatient clinics or bill for treating Children's Heart Network patients for almost a year because the credentialing process "felt like it took forever."

He applied for his medical license in July 2008 and received it two months later. Then, Sheryleen Grothus, office manager of Children's Heart Network, submitted the mounds of paperwork for credentialing. Dr. Curzon says it wasn't until April 2009 that Medicare, Medicaid, and a majority of the private insurance plans credentialed him.

"Waiting out the credentialing process is extremely frustrating," Dr. Curzon said. "Day in and day out you never know where you are in the process, and it's beyond your control. In the meantime, I felt like I wasn't contributing to the practice. My partners never made me feel that way, and they understood how helpless I felt. They'd felt that way once, too."

Ms. Grothus can relate. She manages an office of four pediatric cardiologists at Children's Heart Network and for the past nine years has contracted with Practice Universe to handle physician credentialing.

For her and Cindy White, practice administrator for Central Texas Pediatric Orthopedics in Austin, overseeing the daily activities of a medical practice is no small task. Ms. White manages an office with seven physicians, two physical therapists, five physician assistants, and a nurse practitioner. She says the most important part of her daily responsibilities is to make sure the health professionals at Central Texas Pediatric Orthopedics are paid for their hard work.

Both Ms. White and Ms. Grothus say it's worth it to leave the complexities of credentialing to outside companies experienced in communicating with private and government insurance plans. The rigorous credentialing process that physicians joining a medical practice out of residency or relocating to a new area must endure requires a vast amount of paperwork and months of follow-up to track their health plan and government payer applications.

Texas Medical Association Practice Consulting endorses the credentialing and contract negotiation services of both Innovative Health Resources and Practice Universe. TMA Practice Consulting can refer physicians and practice administrators to either company to streamline the credentialing process.


A Lengthy Process  

Innovative Health Resources co-owner Angela McComb says credentialing takes longest for physicians starting a practice out of residency and for out-of-state physicians moving to Texas.

After obtaining their medical license - a process the Texas Medical Board (TMB) says took an average of 39 days last year - physicians can begin the private health plan, Medicare, and Medicaid application process. Physicians must fill out the Texas standardized credentialing application to be credentialed by hospitals, HMOs, and PPOs. The form and more information about TMB's physician licensure application are available on the TMA Web site's " New to Texas " resource page.

Becoming a Medicare- and/or Medicaid-participating physician involves separate applications. Ms. McComb says physicians can't even begin Medicaid credentialing until they've completed the Medicare process.

TrailBlazer Health Enterprises LLC, the Texas Medicare carrier, says Medicare Part A enrollment for initial applications takes 47 days, while Medicare Part B takes 34 days.

Medicaid credentialing can be held up by the physician background check alone, which can take anywhere from two weeks to several months, according to Ms. McComb. In a background check, Medicaid looks at whether the physician has any prior or pending criminal charges or disciplinary actions from TMB. According to the Texas Medicaid & Healthcare Partnership (TMHP), the process is complete within five business days after it receives all the necessary information. TMHP adds the time frame "may be extended in special circumstances." An example of a special circumstance is family planning agencies requiring a site visit for health care professionals who provide those types of services.

Ms. McComb says physicians who've recently completed residency and physicians moving to Texas from another state should expect credentialing to take about nine months if they plan to accept managed care Medicaid plans along with commercial insurance plans. She says the process is shorter for physicians not planning to accept managed care Medicaid plans.

Ms. McComb says Medicaid managed care credentialing takes longer because physicians must first receive their Medicare and Medicaid approval numbers before applying for Medicaid managed care. "If a physician is planning on accepting managed Medicaid, he or she has to basically go through three different credentialing processes. A doctor has to have each step completed before starting the next step, which causes the delay," she said.

If a physician isn't just coming out of residency or moving from out of state, says Tammy Luker, chief executive officer of Practice Universe, credentialing typically takes three to six months once the health plans have received the contract, application, and all required credentials. She says a common misconception physicians have about the credentialing process is that it takes only a couple of weeks.

Ms. Luker and Ms. McComb say physicians and practice managers who prepare paperwork in advance and who submit accurate, up-to-date information will have the smoothest experience with the credentialing process.

"Once physicians or practice managers contact us initially, we provide them with a list of the information and forms we need," Ms. Luker said. "After we receive all required documentation from the physicians, we can then complete and forward all documents to the health plans. If the physicians will provide accurate dates for employment history and education, as well as contact information for references, this will aid in the primary source verification process and help us complete the credentialing process more quickly."

To help expedite the credentialing process, Ms. McComb offers the following advice:

  • Physicians should consider obtaining medical liability insurance before their start date. Insurance company credentialing committees won't approve a physician whose liability insurance isn't in effect by the time the committee meets.
  • Try to avoid applying for credentialing during busy times of the year, such as November, December, and the summer. Backlogs are greater at insurance companies and government payers when physicians are completing residency and during the winter holidays.

An additional measure to accelerate the credentialing process and to allow patients to maximize their in-network medical insurance benefits is in the Texas Insurance Code. It requires the health plan to recognize and pay physicians undergoing the credentialing process and joining an established medical group with a current contract as if they were already participating in the plan. (See " Credentialing Legislation Aids Patients .") Without this legal protection, enacted with strong support from TMA, health plans would process these services as out-of-network, making patients pay higher coinsurance and deductibles.

Ms. Luker adds that another common misconception about the credentialing process is that credentials are portable once a physician leaves one Texas practice to join or start another.

"When a physician is with a group practice and leaves that group to start his own practice, he will need to be contracted and credentialed under the new practice information, meaning he'll need new Medicare and Medicaid numbers," she said.



Help With Negotiating Contracts  

In addition to providing credentialing services, Practice Universe and Innovative Health Resources can also go to bat for physicians by negotiating contract rates with private health plans.

Knowing what sets a physician apart from other doctors can aid Practice Universe in negotiating the best reimbursement rates in private health plan contracts. For example, a subspecialist setting up a practice in a rural Texas county lacking that subspecialty is likely to have stronger negotiating power than a primary care physician entering an urban area saturated with physicians in that specialty.

"It helps if doctors can give us a detailed description of the type of medicine they're going to be practicing. We can take those details and determine what makes the physician unique. We can use that information as leverage in negotiations," Ms. Luker said.

Ms. McComb advises physicians not to sign the first contract that lands on their desks without looking at the reimbursement rates.

"It's much harder to recontract and get up to market rates if a physician signs a low-ball contract initially," she said. "It can take many years to get a doctor up to market rates."

Physicians also have to contend with non-fee-related contract terms, which can present pitfalls.

The Austin Law Office of Hubert Bell Jr. offers a managed care contract evaluation service at a reduced rate for TMA members. For $150, Michael Stern, JD, CPA, will review any PPO or HMO contract for legal red flags.

Mr. Stern gives physicians a seven- to 12-page evaluation that spells out what the contract says and means and includes suggested language that can be changed. Physicians can use the analysis as a basis to begin negotiations. For more information about the service, contact Mr. Stern at (512) 469-9006.

The American Medical Association also has tools physicians can use to help them through the health plan contract negotiation process. Click  here  [ PDF ] to view "15 questions to ask before signing a managed care contract."

Common provisions in health care payment plan contracts that TMA's contract review checklist says physicians should look for include:

  • The contract not only requires payment of your fees within a specified number of days, but also provides meaningful incentives for the payer's compliance with this requirement.
  • The contract provides for payment for emergency care services notwithstanding any preauthorization requirements, and defines emergency care in accordance with the understanding of a prudent layperson.
  • The contract does not require you to obtain more insurance coverage or different types of insurance than your current insurance.
  • The contract does not require that you indemnify and hold harmless any other party or agree to be "solely responsible" for any harm to covered patients.
  • The contract provides you the right to reject any new groups of patients or alternate fee arrangements without terminating your right to provide services to existing patients or groups under the contract.

Mr. Stern urges physicians not to assume that a health plan contract is fair and reasonable and suggests they have an attorney review a contract before signing it.

"Once a physician has signed an unreasonably restrictive contract with a health plan, it's difficult to get out," he said.

Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by e-mail at  Crystal Conde .  




Credentialing Legislation Aids Patients

At TMA's urging, the 2007 Texas Legislature passed legislation to help patients who receive services from physicians who have joined a medical group but who are undergoing the health plan credentialing process.

For payment purposes only, the law requires a health insurer to recognize physicians undergoing credentialing and the services they provide as if the physicians were already participating providers in the health benefit plan network. This recognition allows patients to access in-network benefits and subsequently decreases out-of-pocket costs and the likelihood of receiving a bill for the balance.

The legislation, however, didn't define the term "group," and some insurers weren't following the legislative intent of the bill. During the 2009 legislative session, TMA worked to fix that.

To prevent insurers from taking liberty with the definition or interpretation of "medical group," Rep. John Zerwas, MD (R-Richmond), authored House Bill 389. The legislation, passed in 2009, statutorily defines "medical group" as:

  • A single legal entity owned by two or more physicians;
  • A professional association composed of licensed physicians; or
  • Any other business entity composed of licensed physicians as permitted under Subchapter B, Chapter 162 of the Texas Occupations Code.

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January 27, 2016