By Gus Geraci, MD
Gus Geraci, MD, is consulting chief medical officer for the Pennsylvania Medical Society.
We all know how hard it is to recruit a physician these days. No matter the specialty, finding a compatible physician with the right skills is a major challenge.
There’s more on this particular subject coming soon from me in the February 2016 issue of the Pennsylvania Physician magazine, but let’s just assume you’ve overcome all those challenges and actually managed to sign a contract.
Let’s put the physician to work! Right?
Sure, you can see patients, but there’s a major problem: Getting paid for that.
Oh, you did want to get paid, right? So what do you need to do?
Insurers have to credential you – that’s each and every insurer for each patient you see. As a family doc, my practice had contracts with something like 50 or more different insurers.
Realistically, there are probably only two or three that dominate the market where you work, and they’re the important ones. But each and every insurer has to go through this process. It’s very similar. They have to confirm your identity, your credentials and skills.
You’ve hired the physician, and they submitted their credentials (which by the way, is a tremendously laborious and repetitive process), and now it sits in the insurer’s hands. Your start date comes and goes, and you either can’t see that insurer’s patients, or you are welcome to see them but you won’t get paid by the insurer, because until you are credentialed you are not in their network.
Depending on their rules, the patient may get stuck paying more (because you’re out of network), or you may have seen that patient for free, because they don’t pay at all for physicians not credentialed yet. If there were reasonable timeframes for credentialing to be done, that might even be survivable, but months and months and months can go by.
Thirty days seem reasonable, right? I mean, if you sign a contract with a start date 30 days after you accept the job offer, it’s not bad if you can get all your credentialing done before you actually start work.
But what if you start in less than 30 days (not all that unusual), or the contract starts, and you don’t have approval from the insurer yet?
And you wait and wait and wait. Your choice is to not see patients from that insurer, or see them and hope that the insurer has retroactive payment in place (very few do). But some don’t.
PAMED supports legislation (HB 1663) to streamline the physician credentialing process and make it more uniform across all insurers. PAMED is also working closely with the Department of Human Services (DHS) to ensure timelier credentialing of physicians within the state’s Medicaid program.
After discussions led by PAMED, DHS announced that, beginning in 2016, Physical Health Managed Care Organizations will be required to begin the credentialing process upon receipt of a provider’s application and must complete the process within 30 days. Learn more about PAMED’s efforts at www.pamedsoc.org/credentialing.
Some insurers are accused of delaying the process to basically get free service. It’s an economic burden added to a practice or a physician starting a practice. It doesn’t seem fair.
Trying to get something done to make it better is another issue. It’s tough enough to recruit and hire a physician. It shouldn’t be that tough to start being paid by an insurer.
Questions about Physician Credentialing and Revalidation ? or other changes in Medicare, Commercial Insurance, and Medicaid billing, credentialing and payments? Call the Firm Services at 512-243-6844 or [email protected]