Managed care means credentialing holdups

Physicians often wait months for HMOs to process credentials. Delays cost doctors in lost revenues and scheduling problems.

By Jay Greene, amednews staff. Feb. 4, 2002.

Muhammad Wasim Sadiq Ali, MD, a neurologist in Jasper, Ala., spent a year waiting for Blue Cross and Blue Shield of Alabama to approve his managed care credentials. Dr. Ali hired a lawyer to move the application process along.

Michael DeBevec, MD, a family physician in Duluth, Minn., practiced sports and general medicine for nearly 20 years until he had to drop his sports medicine practice after United Healthcare required him to be board certified.

Got a beef?

Thomas Blevins, MD, an endocrinologist, waited weeks to be re-credentialed with some payers after leaving a large group and setting up practice in Austin, Texas. Then he had to reschedule appointments with patients while he haggled over managed care contracts.

Hassles like these with managed care payers are all too common and require legislative and regulatory fixes, said Paul Friedrichs, MD, a urologist in Washington, D.C., and AMA Young Physician Section delegate.

"We've heard of it taking six months to get credentials and listed on panels," Dr. Friedrichs said. "Because of delays in credentialing, physicians are not getting paid or cannot even practice."

As physicians incur larger medical training debt and become more mobile, licensing and credentialing delays in setting up practices can cause serious financial problems, said Patrice Burgess, MD, a Boise, Idaho, family practice physician and YPS chair-elect. "Doctors are moving more now due to spouse and other issues. They aren't setting up practice for 30 years and staying. ... They are in huge debt, and then it takes them months for money to start flowing in from payers if they have credentialing delays."

Some states have already acted to speed credentialing.

Doctors need state legislation to prohibit insurers from requiring board certification, to require speedier application processing and to allow provisional credentialing while awaiting a Medicare provider number for young physicians, Dr. Friedrichs said.

"The problem is we don't know how many doctors have these kinds of delays and hassles," Dr. Friedrichs said. "If payers have a full panel, they have no incentive to expedite my application. If they need you, they will bust their butt and do it faster; otherwise, they have no incentive to put you on their list."

In November 2001, the AMA unveiled a "health plan complaint form" to gather data and anecdotes on the variety of hassles and inconsistencies physicians face with health plans.

"Once we have data, we can go to legislators and show them how bad it is," Dr. Friedrichs said. "I hear about these problems all the time. We just don't have hard numbers."

Some states already have acted to require speedier credentialing. Texas insurers this year will be required to use a standardized insurance credentialing form, said Bohn Allen, MD, a board member of the Texas Medical Assn. Payers in California and New Jersey also use standardized forms and the Assn. of American Health Plans encourages its members to use standardized forms.

"Insurers won't act unless they are forced by legislatures or the federal government," he said. "For young doctors, the biggest problem is getting Medicare participation credentialing. It can exclude them from the program for at least six months in Texas."

Last October, the Centers for Medicare & Medicaid Services implemented a new requirement that allows Medicare HMOs to issue provisional credentials within 60 days for new physicians. The AMA wants provisional credentialing extended to traditional Medicare and that time wait cut to 45 days.

"We really need the government to implement this for all of Medicare and Medicaid," Dr. Friedrichs said. "This will help us change the rules at the state level for private payers."

In Alabama, Blue Cross and Blue Shield in 1999 began looking at community needs for physicians before issuing credentials for its PPO, which covers about half the state's insured population. Blue Cross requires doctors to meet certain cost, utilization, outcomes and quality-of-care standards as a condition of participation.

The Alabama policy often results in credentialing delays of three to six months and discourages many doctors from locating there, said Trey Davis, vice president of primary care with Staff Care, a national temporary physician firm located in Irving, Texas.

"With these hassles, physicians wind up going someplace else," Dr. Friedrichs said. "You go where there aren't these kind of problems. Doctors know which states and payers take a long time, and they avoid going there unless they are from there or have a spouse from there."

ADDITIONAL INFORMATION:

Got a beef?

The AMA offers an online Health Plan Complaint Form (http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/hipaahealth-insurance-portability-accountability-act/file-hipaa-related-complaint.shtml).

You first must register for an "AMA Internet ID." It is free and takes about 10 minutes. You'll need to know your state medical license number, DEA number, Social Security number and the last year you were in residency.
Plug in the information, get your ID -- a digital certificate issued by VeriSign Inc., a provider of Internet trust services, in partnership with AMA -- then file your credentialing complaint.