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How States Are Simplifying Physician Health Plan Credentialing

Analysis  |  By Gregory A. Freeman  
   May 16, 2018

Texas is the latest state to create a simplified physician credentialing system for health plans. The goal is to draw more physicians into Medicaid programs.

The bureaucratic hassle of applying to different health plans is enough to keep some physicians from participating in Medicaid programs where reimbursement levels are lower than private plans, so some state health plan associations are finding ways to streamline the process.

The Texas Association of Health Plans (TAHP) is collaborating with the Texas Medical Association and 19 Medicaid health insurance plans to launch a credential verification organization (CVO) to reduce paperwork for Texas physicians.

Medicaid health plans in the state initiated the effort, responding to physician requests for a simpler process, says Amanda Hudgens, director of special projects with TAHP. The Texas Credentialing Alliance participants include Aetna, Superior, Cigna, UnitedHealth Group, and Blue Cross and Blue Shield of Texas.

"We want to simplify the credentialing process for physicians here in Texas and we're focusing on Medicaid providers because we understand they have a lot of paperwork burdens and administrative requirements to become a Medicaid provider," Hudgens says.

She continues, "The intent is to make their lives a little easier. If providers applied to all 19 plans before this program, they would have had to go through 19 different credentialing processes."

The CVO became operational in April and is required for all Medicaid plans in the state but it is open to commercial plans as well. Participating insurers are expanding it to their commercial health plans, Hudgens says.

Physician participation in the Medicaid program varies across the country, with about 70% of office-based physicians accepting Medicaid, according to data from the Kaiser Family Foundation.

The percentage of physicians accepting new Medicaid patients ranges from 39% in New Jersey to 97% in Nebraska. Texas is in line with the national averages.

The Texas Credentialing Alliance allows physicians and providers to submit credentialing paperwork with multiple Medicaid insurance companies at one time, Hudgens says.

TAHP is working with Aperture, which provides credentialing verification services to the healthcare industry. 

The program is expected to lower administrative costs for providers and Medicaid health insurance plans, save time by eliminating paperwork for providers who credential and
recredential separately with multiple Medicaid health insurance plans, and streamline recredentialing dates across multiple health insurance plans for providers.

"Aperture will provide the primary verification on behalf of all the plans, verifying the providers' credentials, education, [and] malpractice history; vetting that all the information the providers are sending to the plan are accurate," Hudgens explains. "They will send that information back to the plans and the plans are still going to make the final credentialing decision."

A key benefit will be creating a single recredentialing date for the provider, Hudgens explains. Rather than the provider having a different expiration and recredentialing date for each health plan, the Texas CVO will create a single date.

"Providers have to be recredentialed every three years and if they were credentialed with 19 different health plans, they probably would have had 19 different dates to keep up with," Hudgens says. "Aperture consolidates those dates so they only have to keep up with one date moving forward."

Gregory A. Freeman is a contributing writer for HealthLeaders.

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