Getting New Physicians Credentialed Expeditiously

Poor Planning and Timing

One of the most common causes of credentialing delays is simply poor planning. Too often, new physicians don’t begin the application process until they’ve actually arrived in town and started working. This is a costly mistake that can easily be avoided with better foresight and planning.

Think about it from a practical standpoint: if you know you’re hiring a new physician who will start in six months, why wait until they arrive to begin the credentialing process? The documentation requirements don’t change based on when the physician starts working, so there’s no reason not to get the ball rolling early.

The delay is often compounded by the time it takes to gather references and documentation. Responses from references can take weeks or even months to arrive, and until all required references are received by the MCO, the application remains incomplete. An incomplete application means the credentialing process is essentially stalled, with no progress being made toward approval.

NCQA Standards and Compliance Requirements

The National Committee for Quality Assurance (NCQA) has established rigorous standards that MCOs must meet to maintain their accreditation. Specifically, the NCQA “Initial Primary Source Verification” standard requires MCOs to verify numerous pieces of information before credentialing a physician.

These requirements include verifying a current, valid license to practice, the status of clinical privileges at the physician’s primary admitting hospital, valid Drug Enforcement Administration certificates, education and training records, board certification status, complete work history, current malpractice coverage, and the physician’s history of professional liability claims.

While these standards are designed to ensure quality and patient safety, they also create a thorough verification process that takes time. MCOs that are eager to meet NCQA requirements may be particularly meticulous, withholding credentials until every last detail is verified to their satisfaction.

The Complexity of Multiple MCO Relationships

Most medical practices today work with multiple MCOs, each with their own unique requirements, forms, and processes. This means that your new physician doesn’t just need to go through the credentialing process once, they need to navigate it separately with each MCO your practice has contracts with.

Each MCO may have slightly different requirements, different timelines, and different standards for what constitutes complete documentation. This multiplies the administrative burden and creates multiple potential points of delay.

Start Early: The Golden Rule of Credentialing

The single most effective strategy for reducing credentialing delays can be summed up in two words: apply early. This might seem obvious, but you’d be surprised how many practices fail to implement this simple principle effectively.

As soon as you’ve made the decision to hire a new physician (even if they won’t be starting for several months), begin the credentialing process immediately. Don’t wait for them to complete their current position, finish their residency, or relocate to your area. The sooner you start, the more likely it is that their credentials will be approved by the time they’re ready to begin seeing patients.

For newly signed residents, encourage them to begin filling out portions of the application and collecting documentation while they’re still in training. Create an extensive checklist of all the information and documents needed for credentialing, and provide this to new physicians as soon as they accept your offer. This allows them to begin gathering the necessary materials at their own pace, rather than scrambling to compile everything at the last minute.

Designate a Credentialing Specialist

One of the most effective organizational strategies is to designate one staff member to handle all credentialing activities for your practice. This person should be responsible for MCO applications, hospital privileges, Drug Enforcement Administration renewals, and all other credentialing-related tasks.

Having a single point of contact for credentialing activities creates several advantages.

1. Firstly, it develops expertise. When one person handles all credentialing, they become familiar with each MCO’s specific requirements and processes, which can significantly speed up the application process.
2. Secondly, it ensures consistency in how applications are completed and submitted.
3. Thirdly, it creates accountability. There’s one person responsible for tracking deadlines, following up on pending applications, and ensuring that nothing falls through the cracks.

Your credentialing specialist should maintain detailed records of all applications, including submission dates, required documentation, follow-up dates, and approval status. This documentation becomes invaluable when you need to track down delays or address issues with specific MCOs.

Negotiate and Leverage Relationships

Don’t underestimate the power of relationship-building and negotiation in the credentialing process. There are several ways you can work with various stakeholders to reduce delays and streamline the process.

Start by building relationships with your state licensing board. In many cases, you can work directly with licensing officials to expedite new licenses, particularly for physicians who are transferring from other states. Understanding the specific requirements and timelines for your state can help you plan more effectively.

If your practice works with a management services organization (MSO) or similar entity, explore the possibility of delegating credentialing responsibilities to them. Since MSOs often handle credentialing for multiple practices, they may be able to achieve economies of scale and potentially negotiate better timelines with MCOs. Some MSOs maintain centralized credentialing databases that can eliminate duplicative processes and reduce delays.

However, be aware that maintaining credentialing capabilities requires significant resources and expertise. Many Independent Practice Associations (IPAs) have taken on credentialing responsibilities only to have them revoked when they couldn’t meet MCO audit standards. If you’re considering this route, make sure you have the necessary infrastructure and expertise to handle it effectively.

Strategic Hiring Considerations

When possible, consider giving preference to physicians who are already licensed in your state. State licensing for physicians trained out of state can take significantly longer than for those who completed their training locally. While this shouldn’t be the primary factor in your hiring decisions, it’s worth considering as a tie-breaker between equally qualified candidates.

Similarly, if you’re hiring physicians from other practices, consider whether they already have credentials with some of your MCOs. While they’ll still need to update their information to reflect their new practice affiliation, this process is typically faster than starting from scratch.

Billing Under Another Physician’s Name

One common approach is to bill for the new physician’s services under the name of a credentialed physician in your practice. This allows the new physician to see patients and generate revenue while their credentials are pending.

However, this strategy requires careful implementation and should only be used with explicit MCO approval. Make sure to check with each MCO about their policies regarding this practice, as some may have restrictions or prohibitions. Never use this approach with Medicare or Medicaid patients, as these agencies are likely to view this method as fraudulent.

When implementing this strategy, maintain detailed records of which services were provided by which physician, and be prepared to update your billing once the new physician’s credentials are approved.

Temporary Patient Reassignment

Another approach is to work out formal agreements with MCOs for temporary patient reassignment. Under this arrangement, patients who would normally be assigned to your new physician are temporarily assigned to one of your credentialed physicians. The new physician provides the actual treatment, but the credentialed physician is the physician of record for billing purposes.

This arrangement should be formalized in writing with the MCO, and all parties, including the patient. They all should understand that the patient will be reassigned to the new physician once credentials are approved. This approach requires careful coordination and clear communication, but it can be effective in the right circumstances.

Retroactive Reimbursement

Some MCOs will allow practices to hold reimbursement claims until the new physician is credentialed, then submit them retroactively once approval is received. This approach allows the new physician to see patients immediately while ensuring that the practice will eventually be reimbursed for their services.

Before implementing this strategy, make sure you have written confirmation from the MCO that they will honor retroactive claims. Also, be aware that this approach creates cash flow challenges, as you’ll be providing services without immediate reimbursement.

Temporary or Provisional Privileges

Although less common, some MCOs will grant temporary privileges based on an initial review of the physician’s credentials and confirmation of hospital privileges. This provisional credentialing allows the new physician to see patients and bill for services while the full credentialing process is completed.

Unfortunately, provisional credentialing is rarely used by MCOs because the NCQA generally discourages this practice. However, it’s worth asking about this possibility, particularly for commercially insured patients. Note that this strategy may not be available for government-insured patients due to additional regulatory restrictions.

Consider the full scope of the impact on your practice:

1. Firstly, there’s the direct revenue loss from reduced patient capacity. If your new physician can only see 50% of their potential patients due to credentialing delays, that’s a 50% reduction in their revenue contribution to your practice.
2. Secondly, there are the indirect costs of staff time spent managing the credentialing process, following up on applications, and implementing workaround strategies during the interim period.
3. Thirdly, there’s the opportunity cost of delayed practice growth. Every month that your new physician operates at reduced capacity is a month of lost practice development and patient relationship building.
4. Finally, there’s the impact on physician satisfaction and retention. New physicians who experience prolonged credentialing delays may become frustrated with the administrative burden and question their decision to join your practice.