A Publication of the Virginia Medical Group Management Association
Summer 2008
Welcome to the quarterly member newsletter of the Virginia Medical Group Management Association (VMGMA).
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Don't miss the upcoming 'Passport to Paradise' fall conference
VMGMA's board to focus on four-part strategic plan
Northern Virginia managers hold first meeting
Regulations govern verification of credentials
Really connecting in our wired world
Learn more about employment law at VMGMA seminar
Practice Notes is the quarterly member newsletter of the Virginia Medical Group Management Association. If you have feedback regarding this newsletter, article ideas or suggestions, please contact the editor:
Frank Dieter
VMGMA Secretary
Phone:
(540) 373-1331
E-mail: fdieter@fredcardio.com
Regulations govern verification of credentials
by Charles Herbert (Bert) Wilson, III, CMPE
VMGMA Legislative Liaison
Each summer, many medical residents emerge from their programs and start to practice in Virginia. This is the time that many practices have to work with the managed care health insurance plans (MCHIP) to finish the credentials-verification process with these insurers. A number of years ago, the Virginia Medical Group Management Association (VMGMA) worked with the Virginia Association of Health Plans and the Virginia Bureau of Insurance to establish regulations for this process.
The regulations state that written supporting documentation for credentials verification should include:
1) Current valid license to practice medicine in Virginia and history of licensure
2) Status of hospital privileges
3) Valid Drug Enforcement Administration certificate
4) Information from the National Practitioner Data Bank
5) Information on all education and training
6) Specialty board certification status
7) Work history for at least the last five years
8) Current and adequate malpractice insurance
9) Malpractice history for at least the last five years
The VMGMA insists on having time limits because in the past, there had been many problems with the timeliness of credentialing. |
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Many MCHIPs use the Coalition for Affordable Quality Healthcare (CAQH) database to obtain their credentials information — all of the listed items are included in the database. If you contract with an MCHIP, it is important to find out whether the plan accepts information from the CAQH database. If so, then you have to ask one of the MCHIPs to assign your new provider an identification number to be registered on the CAQH site. Once registered, the physician or staff can fill out all the requested data to complete the application. Once the application is complete, it is important to verify with each MCHIP that the application has been received.
The VMGMA insists on having time limits because in the past, there had been many problems with the timeliness of credentialing. The current regulations require the MCHIP to notify the applicant physician within 60 calendar days of receipt if there are any deficiencies in the application. If no deficiency notification is provided, then the MCHIP must complete the credentialing process within 120 calendar days of receipt of the application. There should be very few cases, if any, where deficiencies in the application occur if the CAQH audit process has been passed.
The regulations also allow an MCHIP to grant provisional credentials for up to 60 days while the formal process is ongoing. Provisional credentialing may only be granted to physicians who have completed their residency or fellowship requirements within the previous 10 months. Unfortunately, MCHIPs rarely, if ever, use this category. Even though state regulations allow it, the National Committee for Quality Assurance (NCQA), which is the national MCHIP certification body, generally prohibits or discourages the use of provisional credentialing by their certified plans.
The author of this article, Charles Herbert (Bert) Wilson, CMPE, is Practice Administrator with Dermatology Associates of Virginia, PC in Richmond, Va. His phone number is (804) 285-3418 and e-mail is bwilson@dermva.com.
