Alliance Physical Therapy Partners and Agile Virtual Physical Therapy proudly present Agile&Me, a physical therapy leadership podcast devised to help emerging and experienced therapy leaders learn more about various topics relevant to outpatient therapy services.
Richard: Welcome back to Agile&Me, a physical therapy leadership podcast series. Again, I am excited to welcome back Christine Mulder. Our expert in residence at all things credentialing. So welcome back, Christine.
Christine: Hi, Richard. Thank you.
Richard: Most welcome. So obviously the intent today is to talk a little bit more about credentialing and different components of it in the first episode. I think we did a really good job covering the basics associated with credentialing, but before we dive back into the weeds and learn more about credentialing, just in case the listeners haven’t listened to the first podcast, would you mind just giving a brief introduction about yourself and your experience?
Christine: Yes. I have been with Alliance for 24 years. I have held many different titles, the last 12 years of which has been credentialing. Started out with just three companies and now we are up to several companies, many locations, and many providers. We’ve gone through quite a few changes with regards to providers from a simplicity standpoint to a more complex dive in with enrollment and insurance plans.
Richard: I think your historical understanding and knowledge within the credentialing world, I think it’s really useful because I’d like to touch on how credentialing has changed over the last few years and where it’s going. But anyway let’s dive in specific to that point, actually. What have you seen that has changed, I suppose, to this point? So I know a lot of people talk about the kind of the pre pre COVID and post COVID almost use that as a landmark. But I think from a credentialing perspective, that actually might be quite useful to use because there seem to have been some changes since COVID, but let’s talk about historically in the credentialing world. How did outpatient physical therapy need credentialing? If it did, what was the level of credentialing? Was it the location? Was it the individual? So tell me a little bit of a historical context perhaps up to COVID and then we can then focus on what might have changed after COVID.
Christine: In the beginning, the most detailed credentialing we had to perform was at the Medicare Medicaid level.
That has historically not changed. The location and the providers all must be credentialed with Medicare and Medicaid in order to be considered as participating. BLUES was the other individual entity that performed in the same function. They have remained unchanged. The ones that have changed are your additional commercial plans like UnitedHealthcare, Aetna, Cigna. In the past, they only required notification of a new location being added to the group roster. No individual enrollment was required. Over the years, it has slowly progressed by each insurance company, one by one, now requiring not only locations, but individuals to be credentialed and to be credentialed to their specific locations. Prior to COVID, most applications were submitted manually, so on paper applications. Once COVID occurred, a lot of them have moved to a digital process where we can submit applications through emails. through portals. Most of them now also allow digital signatures, whereas prior they were only manual wet signatures that were allowed. And we used to have to send the original signatures, they couldn’t be photocopied or anything of that nature, so it was a lot of legwork to get applications to providers, have them sign it, and then work on mailing it back to you so that you can compile it together in a packet to send out to the insurances.
Richard: Yes, I remember having to ring up various clinicians and cajole them to do wet signatures and get them back to you within a certain timeframe for you to then produce these massive documents essentially that then had to be mailed. And then obviously they would say that they didn’t get them half the time, but probably a different conversation. So why do you think the other payers or more and more payers have kind of jumped on this bandwagon because commissions haven’t changed, state licensure hasn’t changed, and it’s probably much easier to search databases. So, you know, if it was just federal payers in the beginning, why have all the commercial payers decided that they have to have all this extra bureaucracy do you think?
Christine: I think because they have more of the managed care products. And in order for them to receive their reimbursement from Medicare and Medicaid for providing services or managing services for members who are eligible, they need to make sure that they’re meeting the same CMS standards as what’s set for Medicare and Medicaid. So they’re rolling out on their end the same type of standards. It seems like it would be a much easier process for them to be able to reference the Medicare files when verifying providers, but they still want their own applications submitted, even though they require verification and proof of Medicare and Medicaid enrollment.
Richard: That’s interesting because in the last episode we talked about the fact that for certain commercial payers that were somehow linked to the Medicare products or Medicaid products in order to get enrolled in certain payers, you had to first be enrolled in Medicare. So it’s obvious and evident that you are essentially having to do exactly the same work that you do for Medicare and then have to do it again for a commercial payer. Instead of Medicare allowing that information to be shared, it’s incumbent upon the providers to do double the work essentially.
Christine: Yes.
Richard: It would be far too easy, wouldn’t it, if they actually coordinated and shared information in this electronic world. But anyway.
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Richard: I suppose the other thing is that, again, this is probably an absolutely stupid question based on healthcare in the U. S., are the requirements for credentialing standardized between different payers? Do they ask the same things in the same format, in the same form? But tell me a little bit about the information specific to each payer’s requirements.
Christine: No, they’re not all the same. Some would be nice if they were. You have one payer that will just ask for the provider’s general information, such as name, date of birth, their NPI, CAQH information, and then the specifics of the location information, which they’re going to be rendering, their specialties, and then they’ll go into CAQH because they have access to that provider file, and they’ll finish pulling whatever they need. Then you have the insurances that not only have access to the CAQH file for the provider, They want you to print it out and send it to them in addition with their CAQH ID, which makes no sense because they have access to that same file, but they want you to print it out and send it.
Richard: Yes, really good that we’ve got the technology solution and they still request paper records. Has that made things easier or is it just different?
Christine: It has helped in some formats. When we submit an application online, through a third party portal, one of which is like a validity, we can receive a tracking number and we also see the date that it was submitted so that we have a point of record should that insurance say, well, they never received it. Then we have something to go back on for them to work through their EDI department to find the application to then process it and retroact that employee or that provider back to that date that was requested or when it was filed. Then you have others where, such as UnitedHealthcare, they have an online submission for new providers. You submit it, but you don’t necessarily receive any response back that it was received. When we call and follow up on it in two to three weeks, they’ll say that they don’t have it. But we have no way of proving that we submitted it because it doesn’t give you a date or timestamp all the time. There’s sometimes where it does work properly and it gives you that information, but again, not always.
Richard: Good old UHC. Tell me a little bit more about since COVID, because obviously, by the sounds of it, there’s been a change with regards to how we submit, transitioning slowly from paper to digital, but also I get the feeling that from a processing perspective, things have slowed down.
Christine: Yes, we’re dealing with a staffing shortage at the insurance companies. A lot of the time we will start out with one enrollment analyst and as the process moves along, they’ve either left the company or they’ve been reassigned to another department and we start over again. Or it sits in a centralized email box when it’s submitted. I have pushed this through to a level two analysts for enrollment, but they don’t give any reason why it’s sitting there. It’s like a no win situation. I mean, it’s digital. But until the insurances have a better way of assigning and tracking. It’s going to be a little hit or miss until that’s worked out.
Richard: And I assume the provider has no leverage at all at this point, whilst the payer may say that it takes approximately X amount of time. If it takes longer, there’s no penalty for the payer and the payer has no incentive to do it because, uh, at that point they have to start paying claims if the patient was being seen without credentialing. So am I correct in that assumption?
Christine: Yeah. The insurance has no incentive at all to get providers enrolled. When we call to try and push an argument, like, this is one of our new locations, we need to get this up and going, we have patients that are waiting to be seen, and their response is, well, you can have the member call our customer service line and they can let them know in the interim which providers in their area are participating.
That’s their response. They have no means to push it along for us, but yet, if we were to do anything against the credentialing rules and procedures, They would be all over it and say, Nope, sorry, this isn’t going to work. Or we’re revoking your enrollment and so sorry.
Richard: Again, I live in hope with this question. Let’s say there’s a simple clerical mistake on a credentialing application. You know, you use an abbreviated first name or you get an initial wrong order. Are they kind enough to make the correction and then continue with the processing? Or do they just throw it straight back to the beginning and you have to re enter it from the beginning?
Christine: It really depends on the pair. UnitedHealthcare usually cooperates with regards to that. They’ll just say, well, you have to submit a new application, which starts it all over again. Other insurance groups, if there is an assigned provider rep, they will give you that rep’s information or they will ask that rep to contact you, and then you’ll be able to make that change, whether it be in writing or sending a replacement application, and they’ll continue where they were at in the process. But then you have groups like American Specialty Health where, you know, you have something misspelled or in the case of a suite number of changes in the middle of the process, they will make you start over again. They will not allow you to change it. And if a location is approved and that provider is approved for that location, they end the date. You have to start over again and they will not backdate it. So you lose that possible claim revenue for those dates.
At Alliance, we believe that partnership means creating something greater than the sum of its parts. Our focus is finding physical therapy practices with a strong culture and thriving community and providing them with additional tools, resources, and expertise to take their practice to the next level.To learn more about joining our nationwide community of outpatient physical therapy practices, visit our website at Alliance.org.
Richard: Moving on post COVID, anything else that’s changed apart from more of an electronic submission perspective, and then also what sounds like essentially a longer credentialing time for it, longer timeframe in order to get successfully credentialed. Anything else that’s changed or is that really pretty much it?
Christine: No, that’s really pretty much it. Longer times, even though it’s digital. Because they’ve become more formal and, uh, strict in their quality process when enrolling providers. And then there’s just flaws in the digital process, in my opinion, I believe it. They’ve tried to rush through doing a digital process and now we’re still working through those kinks.
Richard: So that’s the past and present. I’m always interested in the future. Where do you see credentialing going in the future? Do you see it becoming even more of an initiative burden, which I can’t really believe it’s possible. Or do you think that they’ll wake up one day and say, you know what, let’s have a centralized depository and every single payer will go into that depository and just pull out the required information automatically. And companies don’t have to do all this laborious, excessive paperwork that takes a lot of time and costs a lot of money. So what’s your thoughts?
Christine: Well, I think it’s going to become more. digital. The players that do require paper applications, not only are they going to stop having them emailed, I think they’re going to start using more of these third party portals to be able to send digital applications that will then link with their system. The hope is that they will continue that automation to match what we currently do for Railroad Medicare. When a provider is enrolled in Medicare, We then just have to go on a portal, we input their name, their NPI, their Medicare ID number, and we request participation, and it sends it back to you within a matter of seconds, and that’s the enrollment process. I mean, that would be the best all around scenario if, if they could work towards that, really. Yeah, I mean, I don’t know what the holdup is or what the issue is with commercial payers sharing information with Medicare and Medicaid. But it would really relieve a lot of the burdens. We would be able to get providers enrolled much quicker and much easier.
Richard: Now, from a very practical perspective, I’m a private practice owner, I want to get enrolled or become in network with a certain payer. Where do I find the information to allow me to put together a submission or apply? I assume it’s through the payer’s website to start with. Is that correct or incorrect?
Christine: Yes, that’s the best way to start. My best suggestion would be to go to the insurance website and look for the provider relations phone number and reach out by phone and have them walk you through the website to verify if you can submit electronically and or whether you have applications that you need to fill out and then email in.
Richard: Great. We’ve mentioned online submission, but technology is marching on and hopefully we can, you know, leverage technology going forwards. Is there software on the market that helps with this credentialing requirement? If there is perhaps a couple of examples you might have, and what does it actually do?
Christine: Sure. There are some credentialing platforms out there. That not only stores the provider’s information. It will allow you to send out reminders to providers on license renewals, reminding them to send in any updated CVs. That you need to submit to insurance. It allows you to track when insurances are due to recredential for a provider. Some of them also will set up a portal link between you and the provider to send applications so that they can digitally sign applications and bring them right into the system. And or they will take that completed application with signature and forward it onto the insurance plan and then also store it within the system. A few of them are through, like, a group called VerityStream. They have a product called CredentialMyDoc or CredentialStream. There is WebMD that has some of their own products. So there are products out there. They’re just at different levels. Some of them are mostly built for physicians, so you sort of have to tweak it to make it work for, you know, some specialty practices, like in the instance of PT and OT that we deal with.
Richard: Would those products be useful, helpful for a smaller independent practice, or really are we looking at kind of a multi site practice to make that? Economically viable or necessary, would you say?
Christine: I would say it would be more economically viable for, you know, multiple offices. Not for something like it’s a small office, two, three offices with like maybe five providers.
Richard: Move on a little bit. I know that there are third party credentialing entities, for instance, Northwest Rehab Alliance PTP, and I’m sure there’s multiple others. What are these groups, and how can they help?
Christine: Well, what they do is they are third party delegated credentialing entities, which basically means they have a board that fulfills what is required within any particular insurance plan with receiving, reviewing, approving, and enrolling a provider, and then they transmit that information on to the insurance. It has to be an agreement between that third party and the insurance plan. It’s not something that they can do internally and then send it over to the insurance and say, we did this so, you need to enroll them like we have. They perform checks and balances for the insurance plan. The upside to that is it removes some of the burden with having to, you know, complete applications. In most plans, you are going to submit a generalized short application to them. They will then credential the provider, approve the provider, and transmit the information. The downfall with that is that they usually will charge you either by provider, by location, the group, or by all means, all three. That can be quite burdensome financially if you’re a smaller practice. The positivity with that on the other side is that they do typically have higher reimbursement rates. But you have to weigh that against, you know, how often you’re going to see those members.
Richard: Am I correct in saying in certain instances They may actually have exclusivity or they may have the ability for providers to become in network with certain pairs that they might not be able to independently obtain.
Christine: Correct. In the instance of PTP, Preferred Therapy Providers, in California, you cannot contract directly with them. They delegated it to PTP. For physical, occupational, and speech providers, you cannot participate with Aetna unless you are a member of PTP.
Richard: And obviously, if you go through that entity in order to be able to access the Aetna in network members, then there is that same fee associated with it. Is there any other important information about them or idiosyncrasies or pros and cons? If I’m an independent practitioner, you’re obviously the cost associated with using one of them, but there are some advantages, obviously. Anything else to help the independent owner make a decision on whether to use or not use these types of entities.
Christine: Yes, with using these entities, you are bound to go through that entity with any claims enrollment issues that you have with the third party as in relation to Aetna. You’re not able to go directly to Aetna with any issues. You have to go to that third party entity and go through their process to resolve any issues. Should they delay or have it once a month? enrollment process for providers, you can’t get around that in any way. You can’t submit an application sooner than if you were to directly contract with an insurance company. You’re bound by their once a month enrollment status which means basically if you don’t get an application in before it goes to board, you’re not going to get approved for that month. It’s going to be possibly anywhere from two to four weeks later before your provider will get approved and enroll with the insurance. Also, with some of those they do restrict it to individual ownership. They don’t allow any sort of corporate ownership. So that’s something you have to be cognizant of as well. The upside to it is, again, that it relieves some of the burdens, and you do get some of the higher reimbursement rates.
Richard: Just on the whole. Is the credentialing process faster if you go through one of these third party entities or if you do it yourself?
Christine: It really depends on the third party entity. Some of them have a really good reputation for getting it through pretty quickly and they do provide correct information as far as effective dates and that you need to wait before submitting claims and that you will be enrolled effective their approval date. They just have to wait for the insurance to upload that information.
Richard: And we’re quick enough to kind of single out those that perhaps aren’t hitting the mark. You mentioned that some have a really great reputation.
Christine: PTP can be very good. You have direct individuals that you would report to and that you would work with. You just have to be very clear and concise on what your expectations are, and they will do their best to meet those expectations.
Richard: Now for large entities, and I assume that it might even be available for smaller entities. I’ve worked for organizations that actually outsource their credentialing services completely. So I assume that there are actually companies out there that will take on this responsibility. Now let’s not go into whether they’re good or bad or efficient or effective at their role, but there are credentialing companies, correct?
Christine: Yes.
Richard: Are there ones specific to therapy that you know of, or is there any information you might have about them? Obviously, in the role that you have, we haven’t had to use them.
Christine: I don’t have too much knowledge in regards to those entities. There are quite a few out there that are smaller, and then you have your larger ones that will perform credentialing for you as well.
Richard: Any other topic or anything that we’ve missed at this point when we’re talking about credentialing that the listener might find helpful?
Christine: I think you’ve pretty much covered all the questions.
Richard: Well, that’s very kind of you. So really, thank you so much, Christine, for sharing your knowledge, both on the mechanics of credentialing and really looking at it at a macro level and looking perhaps at the crystal ball.
I think there definitely seems to be job security for credentialing specialists in the future by the sounds of it. And hopefully we live in hope that a lot of the payers will streamline the process. But once again, I won’t hold my breath for that one, but I really appreciate the time today.
This podcast was brought to you by Alliance Physical Therapy Partners. Want more expertise and information? Visit our website at AlliancePTP. com and follow us on social media. You can find links below in the description. As always, thank you for listening.
