Single Credentialing Form Eliminates One Administrative Hassle
Medical Economics Feature -- July 2000
By Laurie Stoneham
When Michael O'Malley, MD, decided to return to private practice in Galveston after 2 years in a salaried position, he had no idea it would take 6 months to get back onto the panels of health plans whose members he'd been treating over the past 8 years. Practicing for less than a decade, this young physician has gotten a huge dose of the complexity of medicine these days.
Dr O'Malley didn't have to know much about the credentialing process when he joined a group practice right after his residency in 1992. Most of the forms were completed for him. But he did experience the stress of several mergers, and when Phycor stopped paying internists, he accepted a position as a hospitalist with The University of Texas Medical Branch at Galveston in 1997. And when downsizing eliminated that position last fall, the wiser, but still undaunted, physician decided to open a solo practice.
That's when the credentialing paperwork nightmare hit him. "I called Aetna right away and was told that because I'd been on the panel previously all I needed to do was fax over new information so they could assign me a new provider number."
That was only one plan, though. He had to join and fill out the credentialing forms for the independent physician association (IPA) in order to see Medicare health maintenance organization (HMO) patients. And there were the forms for several other plans not included in the IPAs and the clearinghouse for the smaller plans. All wanted the same factual information that never changes, but all required it in a slightly different manner.
Hundreds of pieces of paper and hours later, Dr O'Malley still hasn't been readmitted to Aetna and is just now starting to see a steady cash flow from the other plans.
"I thought it was going to be some trouble, but never this. And thank God I'm board certified and have never been sued!"
Actually, Dr O'Malley's load is comparatively small. Some physicians are on the panels of as many as 25 different plans and four or five hospitals, all of which demand reams of duplicative paperwork.
"You can't short-circuit the need for the credentialing process," said Karen Batory, director of the Division of Public Health and Quality for the Texas Medical Association. "It's essential quality control. It's what gives the hospitals and the health plans the ammo they need to tell the people that regulate -- Medicare and so forth -- that they're actually contracting with people who've truly got the necessary skills."
"We've created layers and layers of redundancy to arrive at essentially the same decisions regarding any physician," says Stan Pomarantz, MD, an emergency room and urgent care physician, who has been a leader in eliminating some of the frustration Dr O'Malley had to endure.
A common credentialing form is now available for physicians seeking new credentials or renewing existing credentials that are necessary for participating in health plan panels, obtaining hospital privileges, and becoming members of physician groups.
"We're trying to do what we can to help physicians eliminate unnecessary hassles in their offices so that their practices can be more efficient and they will have more time for the delivery of patient care," Ms Batory said. "This initiative is a prime example of how we know we're going to save the doctors time and hassle."
The initiative was spearheaded by the Dallas-Fort Worth Business Group on Health (DFWBGH) and has turned into an example of collaboration at its finest, thanks in large part to the support of TMA and a number of its physician members, as well as health plans and IPAs in the Metroplex and county medical societies around the state.
The tension between health plans and physicians is old news, particularly in the Dallas-Fort Worth area. As a means of bringing the parties together and trying to mend some fences, DFWBGH invited the area's heavy hitters to a meeting last September. "The whole idea was to create a collaborative model to achieve an initiative," said DFWBGH Executive Director Marianne Fazen. "Participants were asked in advance to identify issues of importance so we could address solvable problems."
The turnout was excellent. Health plan chief executive officers and physician leaders attended the meeting, at which three areas of concern were identified, "administrative simplification" being one of them. Dr Pomarantz, who has had years of administrative health care experience working with health plans, an IPA, and credentialing verification organizations, was appointed to chair the workgroup on the common credentialing form.
There was clearly animosity between physicians and health plans at that first meeting, Dr Pomarantz recalls. "Some physicians were skeptical about the process and wondered if this would be another forum to talk a lot but not get anything done. Some left the meeting saying, 'been there, done that, so this time show me.'"
But this initiative was not designed "to be a gripe session," Ms Fazen emphasized. "Our mission was to accomplish results."
And accomplish results they did.
The first couple of meetings were devoted to getting focused and deciding what the group's mission would be, according to Dr Pomarantz. At the October meeting, the group determined that the credentialing process could be streamlined.
Dr Pomarantz teamed with Virginia Moore, MD, then medical director for Prudential/Aetna Health and now senior medical director for medical services for Aetna US Healthcare in Maryland. He says they agreed that several things needed to happen in order for results to be achieved.
They realized that every organization meticulously formulates different questions and requirements that are specific to that entity on its credentialing application. "We couldn't get 25 lawyers together to discuss all the attestations and other legalese that go into these documents. So we decided to establish a section of the application that addressed specific requirements."
Thus, the application was split into Part I, which contains essentially demographic and historical data that change very little. Part II was reserved for specific inquiries.
Dr Pomarantz added, "We also had a 6-month window to complete this first task, and we knew that if we didn't reach agreement quickly and get a document out for review, it would be dead in the water."
Michael Darrouzet, executive officer of the Dallas County Medical Society, took a baseline form developed by the Medical Society Credentials Verification Organizations of America to the next meeting held in early November. He explained that this group spent 2 years ensuring that the form met National Committee on Quality Assurance (NCQA) and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards, and had been accepted by key users at the national level. Mr Darrouzet pointed out that because this was a neutral form that already had undergone rigorous review, it was a good starting point and "there was already a lot of confidence in this document."
A line-by-line review of this form occurred during an intense meeting attended by 25 people who understand the credentialing process. Mr Darrouzet said that any item that couldn't be resolved was automatically transferred into Part II. "That kept us moving quickly."
Dr Moore consolidated the changes into a single document that was approved at a January meeting. This form was then distributed to plans and hospitals to undergo credentialing, legal, and executive review to achieve sign-off.
The right chemistry
"The fact that it was a neutral forum was critical," said Ms Fazen. "Physicians, I think, discovered that health plans are not such hard-nosed entities. They came to the meetings and invested time and effort working side by side with the physicians."
The business community provided a "modifying influence," said Dr Pomarantz. "They brought a business mentality to the table, defining the problem and providing a methodology for solving it. They also kept the parties honest; there were no snow jobs. The health plans wanted to look good in front of them." He added, "I think if it were just physicians and plans trying to work this out, we'd still be mired down in rhetoric."
The initiative has resulted in a two-part document that streamlines the entire credentialing process.
Part I, with 44 pages, covers the following information:
Because this information does not change, Part I will be completed only once for an initial application.
Part II covers plan/health system/group-specific information and may include the following:
The common form was first embraced by Aetna US Healthcare, Blue Cross and Blue Shield of Texas, CIGNA HealthCare, Humana, PacifiCare, Texas Health Choice, and UnitedHealthcare, who agreed to accept the standardized form for their Dallas-area networks. They planned to begin accepting the application in addition to their own in June.
In addition to implementation in the Metroplex, Aetna US Healthcare, Blue Cross and Blue Shield of Texas, PacifiCare of Texas, and UnitedHealthcare have indicated they will adopt the common form for use across Texas.
Then in mid-May, TMA hosted a meeting in Austin with statewide stakeholders. Alan C. Baum, MD, of Houston, who was TMA president at the time, described that meeting as a way "to evangelize and multiply and stretch and swell this little miracle." Credentialing simplification was one of the primary objectives of Dr Baum's presidency that ended in May. "Every new hospital, every new health plan, every new IPA that signs on is like a raging bonfire that can consume thousands and thousands of pages of unnecessary, repetitious busywork for the physicians of their communities," he said.
Dr Baum also stressed that the standardized form should help health plans and hospitals because working together can help them cut their own costs of doing business. "This is the marketplace at work," he said. "This is a voluntary, statewide effort to promote collaboration and cooperation. This is each of us working together because it is in our own best interests to do so."
That meeting garnered statewide support. Organizations that endorsed the single form include:
"We see this as a first effort in improving health plan and provider relationships as well as streamlining administrative processes," said Carolyn Dawson, vice president of utilization management/provider services for Blue Cross and Blue Shield of Texas
Not all Dallas-area hospitals, physician groups, and preferred provider organizations have adopted the form. Dr Pomarantz says that hospitals are slower to make changes and more deliberative in their workings.
Lynne Glover, manager of medical staff services at Methodist Hospitals of Dallas, explains that hospitals adhere to JCAHO data verification requirements, while health plans typically follow what she called the somewhat less rigorous NCQA standards. "For example, hospitals must have what's known as original source verification, so each individual entity that a physician has been associated with, from medical schools to training programs to other hospitals, must be contacted to verify accuracy of information." On the other hand, health plans can accept board certification or American Medical Association physician profiles as verification of training, she says.
Aiming for statewide distribution
A new task force has been formed and is being chaired by Mr Darrouzet to finalize the model for implementation. These draft rules and instructions will then be sent to TMA for review and comment. TMA will work with physicians, health plans, and medical societies throughout the state to promote awareness and develop guidelines to help these organizations integrate the common form into their business practices.
Ms Fazen says that this "multi-stakeholder user and advisory group was established so that no one group has ownership and we can maintain collegiality and the collaborative spirit." The task force will continue to work on the issue of streamlining the credentialing and verification process.
Ralph Kimmich, director of benefits and compensation for Southwest Airlines, says he thinks that while streamlining the credentialing process won't result in cost savings for employers, it may help to contain costs in the short term. The more important result of this effort, Mr Kimmich believes, is that "plans and physicians found some common ground and began to build some bridges that may work to relieve some of the tension and get employers and employees out of the crossfire that has existed between the parties."
"There's no doubt that this represents a significant shift among businesses, plans, and physicians. This is exactly the type of cooperation the health care environment needs," said Mr Darrouzet.
And Dr Baum gets to the heart of the matter, "This will allow us to spend more time doing what we need to do -- taking care of patients."
A lot of work remains to be done. Issues such as establishing a secure Internet location and a common site for warehousing the information, and perhaps making renewal timeframes common need to be resolved, Dr Pomarantz says. "The technology exists, and we ought to apply it to streamlining this process."
Ms Glover, president-elect of the Texas Society for Medical Staff Services, whose members verify credentialing information, said she would like to see "in my lifetime, hopefully, a paperless, one-time application process that is done at the national level." This will save medical schools, training programs, and other organizations from being bombarded for multiple requests for the same information." She adds that it is unnecessary for physicians to redocument unchanging information and there is no need for the same information to be reverified.
Dr Pomarantz says repeating the success experienced thus far is what's important now. "One success is an example. The real challenge is to do it a second, third, and fourth time. Then you have built a solid foundation and achieved a spirit of working collaboratively."
Laurie Stoneham is an Austin freelance writer.
Although use of the common form is evolving, here are the principles behind its use: