Synergy - March/April 2014 - 19

hospitals, and other healthcare organizations
verify practitioners' credentials before they
can treat and receive payment for services
provided to patients. However, in the current
environment, each organization has to
individually and independently complete
the review and approval of the applicant's
credentials. The credentialing process serves
as a critical risk management function for
health plans. The credentialing process is
linked to the framework of the Health Care
Quality Improvement Act of 1986. The act
was designed to ensure review of qualityrelated credentialing criteria and a defined
quality process of standards that should be
maintained under any model of credentialing
activity uniformity. The purpose is to ensure
the safety of the organization's members.
Adding to the workload, healthcare
practitioners are also required to maintain
their credentialing information in a current
state with each organization in which
they are associated. Health plans require
re-credentialing every three years at a
minimum. Additionally, all practitioners
must provide similar information to hospitals
during the initial application process, then
every two years for re-credentialing.
All of the Medical Staff Services Professional
(MSSP) work involved in the credentialing
and re-credentialing processes is time
consuming and adds to administrative
costs. As a result of multiple applications for
different organizations, the risk of errors is
increased and time spent correcting such
errors represents additional administrative
costs for practitioners, health plans, and
other health organizations.

Causes for Delays
An incomplete application can include:
1. Missing or expired malpractice
information, including certificates of
insurance that demonstrate expired
policies, coverage amounts, and the
name of the individual(s) insured
2. Incomplete medical education
information, unexplained gaps between
residency programs, incorrect dates,
missing ECFMG number, and date
3. Hospital privileges
4. Work history with unexplained gaps for a
recent 10-year period

5. Negative answers to disclosure questions
with insufficient explanations
6. Failure to respond in a timely manner to
requests for information
After the application is determined to be
complete and the primary source verification
reveals no negative findings, the application
is ready for review. If the practitioner
meets all of the criteria and the application
demonstrates no issues, it is considered a
clean application and is presented to the
credentials committee for review.
The next step in the process is when timing
is critical in getting an application reviewed.
In our organization, the medical director
and chair of the credentials committee
approves clean applications on a weekly
schedule, so the practitioner is rapidly
integrated into the health plan.

committee's actions, and timing is critical
when it comes to getting the practitioner's
credentials approved.

Health Care Reform
January 1, 2014, was the beginning of
the comprehensive health insurance
reform that offers individuals a new way
of purchasing health insurance. If you
work for an organization that does not
offer healthcare insurance, you can now
do so by going to the Health Insurance
Marketplace. The Patient Protection and
Affordable Care Act (PPACA) caused the
creation of the Small Business Health
Options Program (SHOP). The creation
of SHOP through the PPACA means
small business owners should be able to
find affordable health care programs for
their employees.

URAC requires that all practitioners be
notified in writing within 10 days of the
credentials committee's actions, and timing
is critical when it comes to getting the
practitioner's credentials approved.
The standard that describes approval of
clean applicants is located in the URAC
Health Plan Accreditation Guide, Version
7.1 -CR 3.
The credentials committee meets on a
monthly basis to approve additional clean
applications and review those that don't
meet criteria. The credentials committee
may ask for additional information and
suspend the application for further review.
This may result in a month or longer delay
before a practitioner is approved for health
plan participation and begins to schedule
and treat members of the health plan.
The effective date of the practitioner's
application is when the credentials
committee approves the practitioner
or when the medical director approves
clean applicants on a weekly basis. URAC
requires that all practitioners be notified in
writing within 10 days of the credentials

Provisions under the PPACA established a
statewide Health Insurance Marketplace
that would provide a way for individuals
and businesses to buy health insurance.
In Kansas, the Marketplace is run by the
Centers for Medicare and Medicaid Services
(CMS), which is a federal agency.
Understanding the new laws and regulations
has been a lengthy process that will continue
in the years ahead. There will be more to
come on this topic in future Managed Care
Connections columns. ■

MARCH/APRIL 2014 SYNERGY

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Synergy - March/April 2014

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