BY SHARON H. FITZGERALD

Gary Zelizer, TMA Lobbyist

Credentialing with third-party payers just got a little easier for Tennessee physicians, thanks to legislation the General Assembly passed in May. Starting Oct. 1, payers have 90 days from the time providers submit an application to let the applicants know whether they will be credentialed.

“The reason we brought the legislation was that we had heard anecdotes that in some cases–a physician just out of residency or a physician who had moved–it could take months and months and months to go through that whole process,” said Gary Zelizer, lobbyist with the Tennessee Medical Association. “Unfortunately, that has an adverse impact on the ability of patients to access providers and the impact on the bottom line for the provider.”

Within that 90-day window, insurance plans must do three things:

1. Complete their credentialing application process, including whatever verification steps they require and approval or disapproval by their physician committee.

2. Notify the physician of the results of the plan’s credentialing process.

3. Notify the physician whether the plan will or won’t sign a contract, assuming a contract hasn’t already been signed.

“At least within that 90-day time frame, you have some knowledge of what’s going on. You’re not hanging out there for 120 or 150 days,” Zelizer said.

Gabi Brockelsby, clinical director for Murfreesboro-based Dempsey Vantrease & Follis Medical Practice Services, said the new law will have “a huge impact” on the firm’s physician clients. “The most benefit is going to be obtained by those new physicians coming into Tennessee who have not opened a practice yet. If all goes as planned, those physicians could be credentialed by the time they open their practice,” she said. “To a lesser extent, it will speed up the process for physicians who are already open but may not have gone through a credentialing process with a certain insurance carrier.”

To make a go of it, family practitioners need a roster of 3,000 active patients, yet new doctors are doing well to see five patients a day the first month, Brockelsby said. Launching a practice is time-consuming and expensive, and not being in-network for potential patients just adds another hurdle. Do physicians see patients knowing their insurance won’t cover the visit, or do they request payment up front from the patient? “Most physicians lean toward the first option,” she explained. “Would you see a physician who told you that the visit would be out-of-network and there was someone down the street who was in-network? You wouldn’t. This delays the physician’s ability to become a functioning practice and fill the patient volume,” Brockelsby said.

Zelizer said TMA also heard from group practices that add a young physician whose credentialing application then languishes on a payer’s desk. The group’s contract says “until such time as that new provider is credentialed,” yet the new provider needs to pick up nights and weekend coverage. “It puts the provider and the patients in a difficult position,” he said.

Because of legislation two years ago, Tennessee plans must accept the CAQH Universal Credentialing Datasource, a single national process designed to eliminate paperwork and the need for physicians to fill out multiple credentialing applications. CAQH, the Council for Affordable Quality Healthcare, is a not-for-profit alliance of health plans and networks that promotes collaboration initiatives to help make healthcare more affordable and to make administration easier for doctors and their patients. The universal application is one of its most popular programs.

Tennessee’s CAQH legislation certainly helped streamline the process, Zelizer said, and the new credentialing law further eases physicians’ frustrations.

While there are no specific penalties written into the new law should a payer fail to meet the 90-day deadline, Zelizer said separate legislation brought by the Bredesen administration and passed by the General Assembly this session gives the state commissioner of Commerce and Insurance “a new set of hammers.” Previously, the commissioner’s only option was to pull the license of an insurance company that was not meeting legal requirements. “That’s pretty draconian,” Zelizer said. “What this bill does is allow the insurance commissioner to assess a $1,000-a-day penalty for any violation of any insurance laws, not just the credentialing law.”

The credentialing law gives new physicians help in another way, too: On Oct. 1, insurance plans can’t require an active malpractice policy at the time the application is submitted by a doctor. The only exception is if the plan’s accrediting body mandates it. This is a relief to new physicians who would be paying monthly for malpractice insurance but not yet seeing patients. Zelizer added that BlueCross BlueShield of Tennessee is the only insurer in the state that must require, because of its accrediting body, active malpractice coverage at the time of the application.

While the malpractice provision wasn’t a very contentious point in the bill, Zelizer said the credentialing legislation as a whole was battled mightily by lobbyists of insurance plans. Rating plans’ efforts to kill the bill, he said, “On a scale of one to 10, it was an eight.”


July 2007