In and Out of Network: The $900 million annual cost of provider credentialing

Matt Freeman DNP, MPH

“Are you ‘in networkwith Blue Cross? Cigna? Humana? UnitedHealthCare?”

My office gets these calls all day, every day. According to The Washington Post, the average wait time to see a family practice physician is 66 days in Boston, 24 days in Atlanta, and 23 days in Seattle. Dallas was the lucky city with an five-day wait.

New medical schools have scrambled to open; there have been increased enrollments in physician assistant and nurse practitioner programs. Professional schools are working harder than ever to recruit, educate, and graduate primary care providers.

Unfortunately, new primary care providers face massive barriers with insurers.

A licensed healthcare provider cannot just send a bill to an insurance company and expect a check in the mail. Insurers require that the provider undergo a credentialing process, which officially takes about 90 days, but it can take 180 days or more. Or the insurer may be “closed” and not allow the physician, physician assistant, or nurse practitioner to join the network at all.

 

Why Being “In Network” Matters

Even if seeking care for myself, I look to see if the healthcare provider I wish to see is within my insurance network. I am well aware that I have a $4,500 deductible and “in network” providers, and a $6,900 deductible and 50 percent co-insurance for “out of network” providers. In other words, I have to pay half the cost of the patient visit up to $6,900 if I see someone outside of my insurer’s network.

For the first time, the federal government is helping consumers find this information as well: beginning in January 2016, www.healthcare.gov will now allow consumers to find specific clinicians before deciding on a health plan to join.

waitingroom2

 

What is Credentialing?

Credentialing is the process used by health insurers to permit a healthcare provider to become a part of their “network” or “panel.” It involves a review of the provider’s credentials and approval of a committee. It is estimated to cost $900 million annually. (That figure is limited to physicians, and does not include physician assistants or nurse practitioners, who go through the same process.)

Insurers rightfully want to provide their enrollees with high-quality care. They seek to verify that the providers “empaneled” in their networks are appropriately educated, board certified, and do not have licensure sanctions or malpractice cases indicative of a pattern of poor quality of care.

The insurers state that they depend on “primary source verification,” meaning that they will not accept a photocopy of a diploma, transcript, or board certification. They want the information directly from the academic institution or certifying body.

Although this appears to be a logical step to prevent fraud, insurers are overlooking the fact that state boards require this information in order to issue a license. For example, my state licenses required a copy of my transcripts, proof of an internship, proof that I passed all my of board exams, written letters from the academic programs from which I graduated, fingerprints to be processed by the FBI, and a search of the National Provider Data Bank for licensure sanctions and malpractice cases.

If all of this is required to be licensed, why would an insurer need to repeat the process? Thus far, nobody has been able to answer that question.

 

The Process Starts Over Every Time a Provider Moves.

After months of “primary source verification,” a provider faces the same process from the beginning if he or she moves practices. Insurers tie each provider to a federal tax identification number. The minute that changes, credentialing has to start over.

Insurers may have specific requirements like hospital admitting privileges, “on call” services, accommodations for disabled individuals, and so forth. Likewise some practices offer a wider array of services than others, but these are small changes. Why would an insurer need to re-verify that a degree, certification, or license have been issued just because a provider moved to a new practice?

I have been re-credentialed by insurers at least three times even though my degrees, certification, and license did not change.

 

The Failed Solution

In 2002, the Universal Provider Datasource began. This gave healthcare providers and insurers are central databank of credentialing documents: certifications, employment history, diplomas, licenses, and so on.

The idea was that a provider has a unique code with the databank, and he or she then grants insurers access to his or her information. No need to fill out page after page of the same questions.

But it actually serves no clear purpose. The Universal Provider Datasource, now part of the Council for Affordable Quality Healthcare is a self-report system. Clinicians submit their information, attest to its legitimacy, but it is not verified.

Instead of streamlining the system, it just adds an additional step to a cumbersome process.

 

Even “Primary Source Verified” Information is Wrong

I am “in network” with one particular large insurer. Patients can select me as their primary care provider, and I show up in their list of available PCPs. But the information listed is wrong. Despite careful “primary source verification,” I am listed in the wrong specialty, and the system shows me as having been in practice for three years (I have been in practice since 2004.) Perhaps their “primary sources” included imagination and fuzzy math.

I suggested that they change my specialty in particular (they listed in my family practice, which I am not.) They did not change anything. It is unfortunate that I appear less experienced than I am based on their web site, but perhaps I should be willing to accept that as a compliment to my youthful appearance.

 

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The Closed Network

A number of large insurers have shut the door to new primary care providers. Despite the shortage, these companies have decided that their patients should pay more.

For example, two insurers in my area are “closed” to new providers. The refrain I often hear is, “I called my assigned primary care doctor, and the wait to get in was three months.” It’s just as common as, “The office said that they will not see me because I have not been in for 18 months.” That leaves the patient with the option of paying the higher costs of an urgent care, the emergency department (for a non-emergency), or the expense of seeing an “out of network” provider, which is typically double the out-of-pocket cost.

When I looked at one particular “closed” network, I searched on their web site for primary care providers within 15-mile radius. Most of the names were listed two or three times, so it took a while to filter the list. Then I cross-checked the names against the state registry: one had a cancelled license and lived more than 2,000 miles away, one specialized only in geriatrics, another was a kidney specialist, several were cardiologists. Good luck finding an actual primary care provider.

 

Closed Networks Erroneously View Primary Care Providers as Interchangeable

The relationship between a patient and his or her primary care provider is reassuring, potentially life-saving, and a critical component of disease prevention and management. Everyone has different needs: some primary care providers specialize in certain areas: women’s health, people with HIV, patients who speak a primary language other than English, the elderly, LGBT populations, the hearing impaired, etc.

Although insurers claim that they “consider” providers with special skills or experience for closed networks, this is—at least anecdotally—untrue.

 

Is this this Anticompetitive?

Yes. The system favors large conglomerates.

The balance of power lies with the largest provider groups and healthcare institutions. For example, when hospitals merge, they end up with two departments offering the same service: two groups of surgeons under the same umbrella holding company. The two provider groups have greater bargaining power with insurers.

Established practices do not want the networks to be open either. For example, a study of Florida hospitals demonstrated marked price increases beyond inflation and without accounting for changes in quality of care.

Insurers could also argue that they may open networks based on patient quality data. A closed network might be swayed into accepting a new primary care provider if he or she demonstrated high marks for meeting the standard of care for diabetic patients. But what if the practice has comparatively few diabetics? Or what if the practice inherits a large number of poorly controlled diabetics, and the patients’ data will give the illusion of substandard care.

 

 

Financial Motivation for Fewer Credentialed Providers

Insurers have great interest in keeping their networks small. If there are too many providers, the insurers might face the threat of demand for higher compensation. In 2002, a law suit against Aetna, Anthem BlueCross/BlueShield, and Humana was filed by physicians in Cincinnati. The physicians argued that they were reimbursed below acceptable rates. Humana settled for $100 million and agreed to increase its reimbursements by up to 30 percent.

An even larger network would have meant even greater bargaining power against Humana, and an increased threat to their ability to reimburse below the market rate.

 

Failure of Antitrust Legislation

The courts have been reluctant to take action against anti-competitive action by insurers. Some states enacted “Any Willing Provider” legislation, which mandates that any qualified provider must be allowed to participate in a network. But a decision by Justice Scalia argued that the Employee Retirement Income Security Act (ERISA) pre-empts “Any Willing Provider” laws. Therefore “Any Willing Provider” laws in 27 states apply only to state-regulated policies, not self-funded insurance plans (those typically offered by large employers.) Furthermore, in many cases, the “Any Willing Provider” legislation is limited to pharmacies and pharmacists.

 

How Could This Be a Threat to Public Health?

1. Delays in diagnosis and treatment

Imagine that you or a loved one has an early, brewing pneumonia: fever, chest pain, maybe a little short of breath, profound fatigue. If treated promptly with inexpensive antibiotics, it will not be pleasant, but it is certainly a survivable condition.

If the wait time is anywhere from five to 66 days, that could mean delayed diagnosis, delayed treatment, and the results could be life-threatening.

2. Excess Cost as an Impediment to Care

In the pneumonia scenario, one could argue “that’s why there is urgent care.” True, urgent care clinics and “convenient care” clinics (like those inside pharmacies and supermarkets) should be able to diagnose and treat pneumonia.

I had a look at the cost of going to one of these clinics. I searched on www.healthcare.gov for unsubsidized plans available within my ZIP code. I picked the first three plans from three different insurers.

  • Plan one: urgent care is not covered at all. It is considered a “non-emergent” use of an emergency facility.
  • Plan two: 20 percent co-insurance (in-network urgent care) 50 percent co-insurance (out-of-network.) The same service in a primary care office has a $10 copay.
  • Plan three: $50 copay per visit. The same service in a primary care office has a $30 copay.

Walgreens Healthcare Clinic lists its prices as $89 to $129 for evaluation and management of an illness. Depending on one’s insurer one may or may not be able to recover some of the expenditures from a visit to a “convenient care” clinic.

UrgentCare

 

3. Fragmentation of Care

Since credentialing starts over every time a provider moves, a healthcare provider cannot necessarily take his or her patients along. For example, say that a family practice physician is in a struggling group practice. She decides to break off from the group and open her own practice. Patients will have to wait until the physician is re-credentialed in her new practice. Even worse, if networks are closed, her patients will have to find a new family doctor, and they may face delays in finding the care they need.

4. Misused Funds

$900 million per year in credentialing costs is an unthinkable expenditure of healthcare dollars. The expenditure is often redundant, incorrect, and needlessly time-consuming. A “Gold” health insurance plan is estimated to cost $4,360 annually for the average person. If we standardized credentialing, we could translate that $900 million to “Gold” coverage for two million Americans, or reduce the deductibles and copays for those with high deductible plans that individuals and families cannot afford. We would also provide those consumers with access to a wider network of providers, offering timely care and—one hopes—fewer complications.

 


Potential Solutions

1. The infrastructure already exists.

The CAQH system already collects the requisite data for credentialing, but it is self-report. External verification companies, like Optum, could actually partner with CAQH to flag sections of a provider’s profile as independently verified.

My diplomas, therefore, would always have green check mark next to them, thereby eliminating the need for an insurer to check every time I move. After all, the day I earned by bachelor’s degree, my board scores, and my grade in pathophysiology are not going to change.

 

2. Centralize the “primary source verification” process.

Although insurers do not say so, it would be reasonable to assume that many contract with the same companies—like Optum—to conduct “primary source verification.” Why not allow transparency? Once a provider has been “verified” by one of these firms, there should be no need to repeat the process.

3. Charge an application fee.

Although I would hate to give even more money to insurers, motivated providers could be asked for—say–$100 or $150 for an expeditious review of their credentials.

Insurers concede that their “network” and “credentialing” meetings are held monthly. So this would meant that a new provider could be “verified” and ready to work within six weeks rather than six months.

 

4. Closed primary care networks imperil public health and impair consumer choice. Open the networks.

The shortage of primary care providers is well-documented, and this problem is going to get worse. Insurers should not be fearful of having to pay providers fairly if their networks grow.

Two of the “closed” networks had estimated operating revenues of $15.1 billion and $12.33 billion in 2015. Their financial security is not at risk.

 

References

Bernstein, L. US Faces 90,000 doctor shortage by 2025, medical association warns. The Washington Post. 3 March 2015. https://www.washingtonpost.com/news/to-your-health/wp/2015/03/03/u-s-faces-90000-doctor-shortage-by-2025-medical-school-association-warns/. Accessed 31 December 2015.

Bonfield T. Humana settles doctors’ lawsuit. The Cincinnati Enquirer. 24 October 2003. http://www.enquirer.com/editions/2003/10/24/loc_choicecare24.html. Accessed 30 December 2015.

Noble A. Any Willing or Authorized Providers. National Conference of State Legislatures. 5 November 2014. http://www.ncsl.org/research/health/any-willing-or-authorized-providers.aspx. Accessed 2 January 2016.

Porter ME & Treisberg E. Redefining competition in health care. Harvard Business Review. June 2004. Accessed 2 January 2016.

Potter W. Health insurers watch profits soar as they dump small business customers. The Center for Public Integrity. 25 January 2015. http://www.publicintegrity.org/2015/01/26/16658/health-insurers-watch-profits-soar-they-dump-small-business-customers. Accessed 2 January 2016.

ValuePenguin. Average Cost of Health Insurance (2015). http://www.valuepenguin.com/average-cost-of-health-insurance. Accessed 2 January 2016.

 

All photos public domain

©2016

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