Credentialing Process is Critical

Heather CarterToday’s guest blog comes to us from Heather Carter, a member of the Arizona House of Representatives representing legislative district 15.

Rep. Carter sponsored House Bill 2322 which will streamline and accelerate the process through which qualified physicians are credentialed and authorized to provide care for patients on insurance plans. The bill passed the House unanimously and awaits a vote in the Senate.

As House Health Committee chair, I’ve worked on legislation to help recruit and retain physician talent in the state, including expanding graduate medical education, loan repayment and streamlining licensure processes.

Among these positive steps and other industry changes, consumers today have more health care options and choices than ever before.

But as we create more choice, we have fostered a frustrating system for qualifying new medical professionals to practice and be compensated in Arizona, and it’s time for the insurance industry to address a universal solution because it’s threatening our ability to provide quality care.

Doctors, nurses and other medical specialists relocating to Arizona experience major delays in the credentialing process – the system whereby providers, doctors, health networks and others apply to participate in health plan networks. Similarly, there continue to be significant delays within the provider loading process, which occurs after a provider is enrolled in a network to become part of the plan’s billing system.

The key issues:

  • Currently, health insurers are not timely processing the credentialing applications of physicians and other health-care professionals who wish to participate in health insurers’ provider networks.
  • Delayed credentialing compromises patient access to care by delaying the availability of much-needed primary care and specialist physicians.
  • Patients can be exposed to significant and unnecessary financial liability when they are compelled to access out-of-network providers because slow credentialing has delayed access to affordable care.
  • The delayed process results in lost revenue, productivity and untenable working schedules for physicians while awaiting approval.

If we fail to provide better credentialing, Arizona will continue to struggle to find and keep qualified health-care providers and much of the progress we have made will gradually erode.

The longer it takes to get patients enrolled in plan networks and loaded into billing systems, the greater the gap. It’s a lose-lose for a state already struggling to keep and retain physician talent.

These workforce gaps are not only a large burden on our hospitals and physician groups – but also impede the industry’s goal to meet the health-care needs of our growing communities.

Arizona’s population will continue to grow and we need to have a world-class health care system for our residents. Providers and payors need to come together to identify avenues that ensure an adequate workforce can meet the needs of consumers. An efficient credentialing process is key to this goal.

In addition, there are no guidelines to manage how long the credentialing process should take. Delays make it virtually impossible for a physician or provider to care for patients and can take up to 120 days after the professional has submitted their application.

It’s worth noting that the Arizona Health Care Cost Containment System, Arizona’s version of Medicaid, mandates its health plans meet timelines for credentialing and load. Whereas, the private health plans do not.

We need a better system to manage the process with legislation that fosters predictability and accountability in the credentialing process. A standard and mandated timeline for completing the process needs to be enforced, with repercussions for those that are not abiding established process.

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s