Managed Care - INFO

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No matter what program you participate with, every health care provider has to participate in a credentialing program. This is important because the patient must have confidence that the medical provider who is rendering service to them, is qualified and licensed. We have listed a definition of credentialing below.

CREDENTIALING - a process performed by the insurance company to approve a provider who applies to participate in the insurance company's network.

Most credentialing programs are administered through the Provider Services Department within the healthplan. Lets look at a typical credentialing program.

A credentialing program consist of two major components:

1. The initial credentialing of new providers and facilities

2. The recredentialing of existing providers and facilities.

Initially, the physician must fill out a provider application which most health plans call a Provider Information Form (PIF). The physician must also sign a contract with the health plan, send information about their malpractice insurance, supply copies of licensure, evidence of a DEA certificate, and any board certification which the physician has received. Finally, the physician must sign a release which will grant the health plan the right to check and verify the information supplied by the physician.

After the Provider Services Department has completed the verification of the information supplied to them by the physician, a recommendation by the Provider Services Department will go to an internal Peer Review Board for approval or denial of the physician. The Peer Review Board will render a decision based on a factual review and verification of the information supplied to the health plan.

If the Peer Review Board denies the applicant, the health plan will have a process that the physician can take to appeal their decision. The physician will be explained why the denial has occurred and be informed of the appeal process via letter. If the physician has been approved to become a provider for the health plan, they are notified by letter.

Under the recredentialing program, the entire initial process is implemented every two years. This process is as important, if not more important than the initial credentialing of the physician. Credentialing gives the health plan an idea of what a physician has done or can do, but does not tell the organization what a physician is currently doing. Recredentialing can give the health plan a clearer picture of what the physician is currently doing and if he/she is operating in compliance with the established policies and procedures of the health plan.

The Art of Outsourcing

Running a managed care operation is difficult. Every year another administrative body imposes new regulations and conditions on your business plan. Some standards obviously improve your products and services, others simply add to the increasing cost centers located within your organization.

Credentialing provider’s for any organization often appears on paper to be of little or no consequence. Buy a computer, hire an administrative person, and get the work done. Yet in application, credentialing and privileging physicians, allied health and ancillary providers is a huge cost center. Recent studies have indicated that the average organization with 6000 providers spends $3,780,000.00 dollars per year in staffing, supplies and additional costs. By applying the below listed formula, each file costs your organization $300.00 Compare that to outsourcing all or a portion of your credentialing and verification needs to a Credentials Verification Organization (CVO) where the average file price is $75.00.

For your reference the following formula has been included:

CVO’s have been in existence since the mid 90’s. Once run out of managed care organizations who looked to sell their mandated verifications to affiliated clients, CVO’s are increasingly independent organizations with the sole objective of processing provider files. Where once a Medical Staff offices allowed managed care arrangements to delegate verifications to them, the increasing pressure of NCQA, JCAHO and URAC auditing standards has made this policy unwieldy. Delegated arrangements require annual oversight and auditing by the Delegate. But most importantly, do you really know what is in the file if you don’t processes the data yourself? What may not be a large issue to one organization could very well be a giant quality of care problem for your organization.

CVO’s are insured and often certified organizations that handle your network needs. Most CVO’s will provide the following services: obtaining new and reappointment applications from your providers, verifying the files in accordance to any of these three standards: URAC, NCQA, JCHAO, supplying you with a completed file of documentation and continually forwarding to you updated information regarding Sanctions, Licensure, Certification and Insurance. This is called outsourcing: the managed care arrangement is now able to reduce processing staff and simply have one administrative person who is able to coordinate Credentialing Committee Meetings and update provider directories.

One of the major benefits of utilizing a CVO is that as verifications are the sole focus you are guaranteed a faster turnaround time, lower administrative costs, experience, database management and reporting, reduced duplication and administrative burden, reduced liability and the ability to dedicate staff to other departments.

Many types of companies utilize CVO’s: Provider Hospital Organizations, Managed Behavioral Health Organizations, Individual Practitioner Associations, Managed Workers’ Compensation Arrangements, Multi – Specialty Organizations, Preferred Provider Organizations, Provider Networks, Skilled Nursing Facilities. In short, any agency currently reviewed by State, National or Local health care agencies needs to be sure that the providers they are promoting meet the highest standards possible for care and quality.

Finding a CVO can be difficult. Cambron Credentials, Inc., located in the Greater Tampa Area has been in business for the past three years. This organization is compliant with all national standards and offers special modifications to their process that may not be available from larger national chains. Cambron Credentials, Inc. specializes in the personalized approach for smaller (under 200 providers) organizations.

All companies running a Credentials Department should review their budget on an annual basis: ask yourself if the funds you are currently spending offset the work that is actually being done. In some cases, keeping your operation in house and obtaining consultants to streamline your verification process is the most cost effective choice. Others may find that the amount of money being sent to the “Credentialing Cost Center” does not offset any in-house advantages. Should you find that your current system needs to be streamlined, a consultation with a reputable CVO may be in your best interests.