All Things Credentialing: Part One

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: So welcome back to Agile&Me, a physical therapy podcast leadership series. This episode and all being well, I'll have a part two as well. We're going to talk about the really exciting world of credentialing. Whilst actually it might not be that exciting, it's certainly critical and increasingly critical to running a successful business. And I have the pleasure of speaking to Christine Mulder, who is actually extremely experienced as it pertains to credentialing for outpatient therapy. So, Christine, welcome, excited to have you as a guest and learn more about this world of credentialing.

Christine: Hi Richard, thank you for having me.

Richard: I think this, instead of a world, it's probably a dark art of credentialing, isn't it?

Christine: Oh yes, it can be. For sure.

Richard: Before we dive in, I always ask guests to introduce themselves. We'd love to know your background and experience as it pertains to kind of credentialing and the world of therapy.

Christine: Yes, I have been with Alliance for 24 years. I've held many different titles throughout my tenure here. The last 12 plus years have been with credentialing and enrollment for providers, which was quite the task as we've grown, but with all the roles that I've held, it helped put in perspective the need and all the ins and outs with regards to credentialing for providers.

Richard: I would imagine the job, even compared to five years ago is completely changed, but I can't imagine the amount of change as it pertains to credentialing over that extended period of time. It must be remarkable, really.

Christine: Yes. In the beginning insurances, we only had to credential our locations. We weren't required to credential providers as long as they were licensed, they were good to go. But as CMS has changed the rules and regulations and the commercial plans have started taking on some of the managed care plans, they are now taking on CMS's rules and regulations, which now requires almost every provider out there to have to credential and enroll with the insurances.

Richard: Yeah, we're going to definitely dive into the weeds there because it just seems to me as a leader that it is a minefield. But anyway, let's kind of go to the beginning. When we talk about credentialing, what actually are we talking what is credentialing? You know, if we're a private practice owner trying to start a practice, I think sometimes the credentialing component isn't on the radar. And you know, a lot of people just don't even understand, what it involves or what it is. So could you perhaps at a high level just talk about credentialing as a requirement and what it is?

Christine: Well, credentialing is basically in short, verifying a provider's competence and knowledge and abilities to render in their scope of practice. It's a form of protecting the patients against unqualified clinicians when rendering services, and that is done through a series of verifications verifying provider's license status, their education, any board certifications, work history, and then, also performing any disciplinary or sanction checks with regards to OIG and CMS.

Richard: What I don't understand is why we even need credentialing. Because. You know, the first thing you've said, which is verification of qualifications or the verification of the, the ability of the individual to provide service. And I've never understood, certainly as a foreign trained therapist, this idea, well, you have your license, but then you've got to get credentialed as well on top of that. Why do we need that extra step?

Christine: Well, there is a difference between the credentialing and the enrollment component. Credentialing is basically the insurance. And CMS want to ensure that the provider is fully competent that they are knowledgeable in the field in which they're rendering. They also need to ensure that the provider is staying up to date with their license and performing an continuing education that they need to do to maintain that licensure to also, again, maintain their competence and knowledge within their field so that there is no harm that could be sustained by a patient.

Richard: So basically what payers are saying is, just because you got a license, we don't trust that you're actually competent. We don't trust that you are up to date. We don't trust that you are suitable or effective at treating our members, be those, you know, federal payers or commercial. So they're ultimately doing what I would call, correct me if I'm wrong, kind of just double check, yes?

Christine: Yes. I mean, the state, when you license with the state, you know, they're checking your educational background. You have to take, your test. They deem your competence through a test, but the insurance and CMS goes further.

They're going to dig into any Medicaid, plans that require disclosure of any criminal background that you may have. Some of the estates even require a submission of something any parental issues that you've had not paying child support or anything of that nature. So yeah, CMS really does a thorough dig into your background, so to speak.

Richard: That's really interesting. So technically you can be licensed, you can have a clean license. It doesn't necessarily mean that you're going to be able to get credentialed. So for instance, you know, if there is, I assume if there is a some sort of successful prosecution and you're found guilty of a state or federal law or if there is some sort of background check that exposes certain either past behaviors or you know, restrictions of some sort, they can technically create an issue where you cannot get credential, but you still have a license. Is that accurate?

Christine: Yes. The state doesn't necessarily look at that, but CMS and Medicaid does. They use that as a form of deeming your maybe personality, so to speak. Like, you know, do you have a personality that could, you know, come over into your duties as a clinician that could harm a patient?

Richard: So, you know, based off the credentialing that you've done, what type of questions are there?

Christine: What we see at times is a disciplinary action on either their state license, such as they did not renew their license in a timely fashion. And then we have to submit documentation and explanation as to why it was not renewed timely on the NPI database any disciplinary action like a complaint from a patient, then they require, documentation and explanation in regards to that. When you also enroll with insurances, you have to provide attestations. And some of the questions on there is that you have to disclose if you have had any past personal legal action like any substance abuse you have to verify in a test that you're not using any substances that would hinder your ability to provide effective care to a patient.

Richard: Interesting. So there seems to be a lot of overlap between the kind of the attestation required for maintaining one's license and those for credentialing. I still feel personally that it's almost doubling the work necessarily.

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.

Richard: Now, over the history of doing this for 20 years, is credentialing new or is it something that's been around from day one?

Christine: It has basically been around from day one. It mostly started again with your group practice in locations. And then mostly it was a physician based credentialing that was required. It has moved on to specialty providers with regards to credentialing that specialty providers now have to also credential. Interesting.

Richard: So essentially, if you are a licensed professional, it doesn't matter what healthcare profession you actually are, more than likely nowadays, you're going to have to go through some sort of credentialing process.

Christine: Yes.

Richard: Now, what I've never understood as well and correct me if I'm wrong here, you know, when I worked in hospital, the individuals were never credentialed or certainly didn't go through such a robust credentialing process. Am I correct in saying that? So let's say if I was a licensed therapist in Michigan working for Alliance Physical Therapy Partners, the credentialing requirement is very different than if I'm actually working across the road in a hospital that is based within Michigan. Is that fair and reasonable to say or am I incorrect in that assumption?

Christine: You are correct. But there's a little bit of a difference with regards to outpatient. The outpatient is done through a board that is contained within the insurance companies for hospital base. They have a board of credentialers that perform all of those credentialing and enrollment, verifications, authorizations, approvals within their facility. That's one of the requirements they have as a facility, is they have to perform those credentialing enrollments to ensure any and all clinicians competent and able to render safe and effective care to patients.

Richard: So, you're saying that regardless of whether, let's say, it's a hospital or a stand alone outpatient facility, the credentialing does occur, it just occurs at different places or the level of credentialing actually is different?

Christine: The level of credentialing is the same, but it's done differently as, you could think of it as facilities do it in house. Outpatient is required to do it through the insurance provider.

Richard: So, if there were, certain red flags that would prevent somebody from being credentialed at a standalone outpatient clinic. Theoretically, those same red flags would stop that clinician being able to be credentialed within a hospital environment. Correct?

Christine: Correct.

Richard: Okay. That's helpful. So again, my very simplistic hat on, it does seem that it's almost been doubling of work in many, many ways. As well as credentialing, there's also enrollment, and I'm sure they're closely linked, but what's the difference between enrollment and credentialing?

Christine: Enrollment is establishing a provider to bill for services rendered. Credentialing is to verify their competence and ability to render. So one is to provide competence, the other is to establish the ability to bill.

Richard: Interesting. So they basically get you to jump through a second hoop. So first hoop is basically saying, okay, this clinic, we'll let this clinician work. And then the enrollment is, now we've said that the clinician can work, see our patients. Then we then will allow you to bill for that service.

Christine: Correct. The enrollment, the part of the enrollment is to establish whether the clinician is going to bill independently or have their billing reassigned to a practice to bill on their behalf as a rendering provider within that group. And then it also determines where any monies would be then transferred to.

Richard: If we have any international listeners, I'm sure at this point they're probably thinking how crazy the American healthcare system is at this point. You've got licensure, you've got credentialing, and you've got enrollment. And, on an extra level, We've got to talk about credentialing and how that's done because that's changed somewhat, hasn't it? So I would assume one, the number of entities that require credentialing has gone up over the last 10, 20 years. So probably in the beginning, like most things, it was a certain subset of payers, but that's probably been expanded. And then also more recently is in the past, it has been credentialing the individuals.

But now, correct me if I'm wrong, we've got to credential the locations, and then to add an extra layer, credentialing individuals to specific locations that are credentialed. Now, is that all accurate? And can we unpack that a little bit? Because that adds another layer of complexity, which is just mind boggling to me.

Christine: Yes, I mean, you are correct. When we credential there's different levels. We have to credential the group initially. We have to establish the group's ability to have providers that render. We have to establish how claims will be billed, how they will be paid. Then we also have to do the next level of credentialing a location and enrolling that location under the group. So that any claims that are billed are then paid, not to the location itself, but to the parent company, the group. And then you have to then also credential a provider and assign them not only to the group, but to the location in which they will render. With also some insurances, they do now require us to register or enroll a provider, I'm sorry, credential a provider with every location in which they render. That is not the same for all insurances. There are some insurances that only require us to credential a provider to a location if they render two or more regular days at a location. They don't require us to credential a provider if they're going to cover for a location. But then yet we do have some insurances that do take that a step further and say, no, we want to know any and all locations that they're going to render at.

Richard: So let me understand a little bit better. So we have to credential and enroll the, basically the business, and that is basically the tax identification number. Then we have to credential enroll the individual clinicians. And I assume that is tied to the business. Then we have to credential and enroll the location. And then we have to then, if it's multi site or if the clinician works for more than one geographical location, depending on the payer, more than likely we're going to have to credential them for each location. And then after all that, if I understand correctly, if they don't actually work for a period of time at a certain location, it's automatically decredentialed. Is that right?

Christine: Correct. It varies, and that's another thing that can be difficult to track, depending on the insurance, it's 12 months, others are 2 years. So, if you have a clinician that you enroll as coverage, and they are not utilized as coverage, or they do not render on a regular basis at a location for 12 months, the chances of having them unenrolled at that location can happen. With that, you are also relying upon the insurance company to send you notification that they are disenrolling that provider. That's another issue with the insurance companies with credentialing, is you can credential a provider or a location with specific correspondence addresses. But it's all dependent upon the analyst and what they're choosing or selecting in their system as a location or address to send that information to.

Richard: And I would assume, again, this is my cynical nature, that the insurance companies are, On the ball as it pertains to informing the entities that the providers are being disenrolled or uncredentialed. I'm sure that they send you the notice in a timely manner and they make sure that you received it and everyone's well aware. Is that right?

Christine: I wish. Usually we find out after a provider bills for services and they're receiving rejections, and then we're calling to follow up like, hey, we got this enrollment letter. We've been doing our recredentialing for them as required. How are they disenrolled? And then it just starts a whole new rabbit hole.

Richard: It's kind of the ultimate, isn't it? You know? Oh, yes. You credentialed them. We don't really wanna pay, so, oh, we'll just say they're credentialed again, and you've gotta start all the paperwork again..

Christine: We have issues where they do typos when they go to send it to an email. And we're like, well, we never received it and then you have to start a whole appeals process and basically argument to say, hey, you sent it to the wrong one. So you are required to, to backdate this and, and they will fight you that basically it's a fight to see who's going to break down first and say, okay, fine.

Richard: It's funny, but extremely sad. Now, the thing that probably upsets me the most is the amount of time that this takes. Okay. We know, as we always talk about certain payers don't even cover the cost of the visit, but the amount of time this takes to, let's say a private. Somebody wants to set up a private practice, a clinic location. They want to take insurance, okay. How much time are we talking about to set up a new entity, a new clinic with say a couple of providers with all the, the large payers? How much time would you say the enrollment and their credentialing takes to do that on Ballpark?

Christine: Well, on Ballpark you are looking at four to six months post contract. The first step is you have to obtain a contract with that insurance company and then it would be simpler for them to do an intake of all the credentialing when you submit your request to contract, but they don't do that. You have to do a contract first, and then once they execute that contract, then they send you a request, then begin the credentialing.

And so it takes four to six months post contracting to get a new entity or location up and rolling.

Richard: Yeah, it would be far too sensible to actually combine the different requirements, wouldn't it? But, but on a very pragmatic, practical basis, how much time does it take you as the credentialer and enroller?

Christine: Yes, it takes several hours it usually takes about a week or more to prepare all of the applications because depending on the number of clinicians at a location and the number of locations you're establishing, you have to submit X amount of documents or applications, so to speak, and the supporting documents, such as copy of licensure, sometimes diplomas, sometimes CEUs with it as well. And you have to. Bundle those together and send them as a package or with some insurances, they require them to be sent separately so that they don't get broken apart and pieces are missing and delayed.

Orthotic manufacturers take a one shape fits all approach to solving lower body pain symptoms. They focus on arch support for temporary pain relief, which can lead to inefficiencies and injuries. Bio correct. Knows that everyone has unique needs. Bio Correct is a fully customizable foot orthotic system engineered to address and treat the biomechanical imbalances of your entire body. Bio correct more than just an insert. To learn more, visit us@biocorrect.com.

Richard: The additional layer. So, the key to all this, if I understand correctly, is when you're looking to credential or enroll in the outpatient standalone facilities, it's not as if you can send out applications to everybody at the same time, because you have to do it in a certain order, don't you? In order to credential for certain payers, they require you to actually already be credentialed for others. Is that right?

Christine: Yes, for some of the payers they require you to be credentialed and enrolled with Medicare and Medicaid services. Just due to the fact that they have such a stringent enrollment process and credentialing process, that they use that process as a means to do their own in house credentialing. With that being said, it seems like it should take less time, but in fact it does not. You have to send verification of enrollment with or credentialing with Medicare and Medicaid, but then it will still take three to four months for you to process through their credentialing as well.

Richard: So give me an example of a pair that requires you to already be credentialed with Medicare. What commercial would that be an example of one?

Christine: one of them would be typically a blues Blue Cross Blue Shield will require you to be enrolled in Medicare.

Richard: So, is there a scenario where, as a private practice owner, you can be credentialed and enrolled, well, first of all, contracted, then enrolled, then credentialed with the blues without, being a Medicare credential provider or basically if you want to be with the blues in certain states and certain plans Essentially, they're saying you have to take Medicare

Christine: It if you have it in your contract as a group. If you are only contracted as a commercial blues Then they don't make that a requirement.

Richard: Crazy. So, the only way around this, essentially, is being out of network, not contracted with any payers, and self pay. Is that accurate?

Christine: Yeah. But a lot of the patients can't afford to do out of pocket. Just because they depend upon the insurances. To help with, you know, cost and time and finding and helping them find good providers.

Richard: So let's kind of go down into the weeds a little bit further and, and let's say I'm a practice owner. I've built my practice. I'm ready for bringing on another clinician, another licensed PT, and I've got to credential. So what are the practical steps for that owner? What do they have to do? What information do they have to collect? What's the time frame? Who do they send what? What do they need to get to submit successfully? So very practical basis. Can you kind of outline a new provider to an entity, what they need?

Christine: First thing they're going to need is they're going to need a copy of their active license within that state. They will need a copy of their diploma or official transcripts from the educational facility that they attended for their specialty. From there, they will also then need to reach out to the provider and obtain personal information, such as their legal name. Any former names, dates of birth, Social Security, home address, work history, education history. And then from there, they would take that information and input it on the applicable applications that then need to be submitted to the insurances. You would want to try to get that information from the provider as soon as possible. The longer it takes to get information from a prospective provider delays the amount of time to be able to submit your application and the amount of time it will then take for it to process.

Richard: So they basically want to know pretty much everything apart from the name of the firstborn. And who knows, they might even ask that nowadays. I was going to say they probably want to know your eye color, but they can get that from your driving license or ID card. So they probably already know the eye color of everyone, but certainly it's comprehensive, isn't it? The information that's required to even submit. And then. Once it's submitted, you hope that it's been received and they have done what's required administratively to process it, which is a leap of faith sometimes in assuming that it takes time as you kind of talked about. But, during that time, if the. Therapist sees a patient where they're not credentialed if we're lucky then the payment will be retrospective but for a lot of payers now there isn't retrospective credentialing or payment of services rendered so essentially you are very limited as a provider and what that new therapist who's uncredentialed can bill for successfully during that period, so we're essentially more than likely going to be giving away services for free because the payer has put in hurdles and barriers to, being paid for seeing their patients.

Christine: Correct.

Richard: Yeah, I suppose that's really a yes or no answer, isn't it? Really? Yeah,

Christine: I mean, t's a pretty sad system. When we submit applications, we follow up with the insurances 1 to 2 weeks after submission, just to verify they've received it. And we will usually get Pretty blank statement of, well, you need to give us 30 days for it to be entered into the system. And that's even something where you can submit it digitally. And they still say, well, you have to wait for it to be received. It's like, well, it was submitted electronically. I don't understand why you need 30 days. And then once it's received into their system, then that's when their time clock starts.

Richard: Now, from what I've seen we'll probably talk about this a little bit more in the next episode, but what I've seen is this process is taking longer and longer, particularly since COVID, if I'm correct. And I think the COVID's being used as an excuse, to be brutally honest with you. As most organizations can't continue to use COVID as an excuse or even labor shortages because I would imagine a lot of this is automated from the payer perspective as well. Is this credentialing process taking longer and which are the worst payers to be honest as pertains to the amount of time it takes to get credentialed for clinicians and locations?

Christine: Yes, it is a longer process. We are constantly, you know, fighting, having new analysts that are assigned. We can start out with one enrollment analyst that's working the application and credentialing request, and then they either advance to a different department, or they just are no longer there anymore. So then we're starting off with someone new, and hopefully you get someone that is not new, to the whole system, but just somebody new within that department to where it won't be delayed as long. But our payers that take the longest typically are Aetna, United Healthcare blues, depending on the state. Medicaid can take quite a bit of time. Those are our top payers that take the longest amount of time and then you also have some workman's comp carriers that do take up to six months for them to process. TRICARE has been an issue in regards to HNFS that was managing it. We're hopeful that beginning in January, with it transferring to TriWest as the managing contractor, that it will be a much shorter process. We have some physicians that are a year out that are still waiting for approval.

Richard: So, bottom line is don't hold your breath. If you're lucky, it might be three months, more than likely probably six months, and then even some, you're probably looking up to a year. And as a private practice owner that is dependent upon, cash flow doesn't have the luxury of perhaps being able to move patients to different clinicians and if you're starting out, this is a Huge issue.

Christine: Yes. Very.

Richard: I think the last couple of questions I have is pertains to the basics of credentialing is from what I've hearing really the quicker you can get started with credentialing, the better. Because of the time frames involved. But, if I'm a private practice, I've just recruited an individual, let's say a student for instance, which is common, to start in my practice. I can't get a head start on this, even if I wanted, could I? Because, you know, They have to have certain documentation, one of them is a license, to be able to actually submit the paperwork. So it's not really as if the private practice owner can get a head start on any of this to be able to shorten the length of time where the person or the clinician is uncredentialed. Am I accurate there?

Christine: Yes, for the most part. You can collect their personal information and their diploma or transcripts if they have those available and have that prepped and ready. And then once they receive their license then what we typically do is we'll then input their license information, attach the license, and get it out the door right away. But it doesn't lessen the time that it takes to get them credentialed with the insurance.

Richard: That's pretty depressing again, isn't it? I think, based on what we've talked about, the basics of credentialing and the basic mechanics of how to get credentialed, any words of wisdom at this point?

Christine: The only words of wisdom that I have is document, document, document. Anytime you make a call, you document who you spoke to, the number you called the reference number. If you can get anything in writing when you're trying to work a provider's application, save all of that because it will help you in regards to delays or if it gets lost or misplaced, which does happen, to be able to then have the basis to go back and argue like, well, this is not my problem. This is something that you, your corporation had done. And we would like this retro enrolled back to our submission.

Richard: Well, thank you so much for today. I really appreciate it. I don't think the Blues or United Health Care Aetna will be sponsoring this episode any time too quickly. And again, always a big shout out to UHC because they're always so helpful to providers. So I want to make sure we get that in. Again, thank you. I am looking forward to part two where we'll cover some other additional components of credentialing particularly as it pertains to using perhaps third party credentialing entities that I know many private practices use. Thank you once again and look forward to speaking to you again.

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.