Fed up with the paperwork headaches of physician credentialing, some medical groups are deciding to manage all or part of the process themselves.
Their goal is to streamline credentialing, which verifies doctors' training, board certification and liability coverage.
For health plans and hospitals, physician credentialing is crucial. Health plans must meet certain credentialing requirements to receive accreditation from the National Committee for Quality Assurance. The same goes for hospitals seeking accreditation from the Joint Commission on Accreditation of Healthcare Organizations.
For physicians, credentialing is necessary to obtain hospital privileges and may ease their way to participation in health plans. Unfortunately, it means filling out reams of paperwork for each hospital and health plan with which they are affiliated -- a time-consuming and often redundant process. Because there are no standards for collecting information, doctors sometimes have to provide data several times a year.
"Credentialing is essential for physicians, but it has become intrusively controlling. Physicians are overly surveyed, and the process is becoming a nuisance," says Mir Kator, executive director of Morris-Somerset IPA, the largest independent practice association in northern and central New Jersey, with more than 900 members.
Physicians "generally want to cooperate," Kator says. "But as with anything that's as overdone, takes as much time and has such important career implications, they see (credentialing) as annoying and intrusive. The process can make physicians feel like infants. Given their education, training and responsibility, this is not what we should want to do with people who operate at such a high level."
Responding to physicians' desires to manage the process themselves, group practices, membership associations and private companies are offering programs that handle the entire operation or automate a specific part of it.
Approaches to credentialing and ways in which the process can be changed vary.
In California, health plans often delegate credentialing services to physician organizations and use a standardized form to ease the process.
At San Francisco-based Brown & Toland Medical Group, a physician service organization handles credentialing services for the group's 1,200 doctors. The five-member staff collects and verifies data, and it visits primary-care practitioners to examine medical records and the layout and operation of their offices.
"The (health) plans look to us for one-stop shopping," says Leanna Hudson, credentialing manager of the physician service organization. "What we do reduces their workload considerably and makes their lives easier. It's also important to our physicians. Having us perform the work helps ensure that they're directing their own destiny."
Hudson says Brown & Toland uses its own software program with a "very flexible" database to complete the standardized form. She says plans rejected centralized verification in the past, fearing a loss of control and unreliable information. But she says they may be willing to accept it from NCQA-certified independent credentials verification organizations. The NCQA has certified about 40 CVOs so far and is considering 11 others.
"Groups that have the NCQA certification will be even more valuable in the future," Hudson says. "I can't imagine why a health plan wouldn't want to contract with a group that is certified by the NCQA."
She notes that California's health plans are unique in their willingness to delegate so much authority to medical groups.
"In other areas of the country it's bizarre," she says. "They just don't understand it."
In New Jersey, plans still are very reluctant to give up elements of the credentialing process. Kator says Morris-Somerset decided to offer credentialing in 1994 as a service to physicians and as a way to keep in touch with networks.
Morris-Somerset serves one plan, while three others still do their own credentialing. "It's very hard to fight," Kator says. "They like to keep more control over their network."
She says a significant problem in New Jersey is the lack of standardization and criteria. Each IPA, health plan and hospital operates differently. Like Brown & Toland, Morris-Somerset uses its own database designed to accept the specific information required by the plan that originally contracted with it.
Kator says it's "nice that the IPA can perform this service for a community of physicians who know each other and know that the information will be treated more personally."
One factor that's changing the credentialing process in New Jersey is the arrival of the American Medical Association's American Medical Accreditation Program, which the AMA bills as a single source for physician credentialing information.
Robert Mills, an AMAP spokesman, says New Jersey is the first state in which the program has become operational, with the District of Columbia, Idaho and Montana due to come on board this summer. AMAP expects to be working in 10 states by year-end. Figures are not yet available on how many physicians participate in the program.
AMAP is a voluntary program set up to evaluate doctors against national standards on credentials, personal qualifications, environment of care, clinical performance and patient-care results, according to the AMA. So far, AMAP can review qualifications, verify credentials and conduct site visits. Patient satisfaction surveys and methods for the evaluation of clinical performance are under development.
AMAP charges AMA members $50 to register; nonmember physicians may register for $150. The AMA expects to recover most of its costs from the sale of reports to health plans. Mills says AMAP will not accredit physicians on its own; health plans and hospitals that purchase the reports make their own accreditation decisions based on the information.
The AMA will partner with state medical societies in most areas and contract with NCQA-certified organizations to perform verifications and office site visits.
Mills says the advantage for physicians is they only have to complete paperwork once every two years and that AMAP is much more comprehensive than products from other sources, meeting or exceeding requirements of the JCAHO and the NCQA.
A company that's experienced in dealing with different approaches to credentialing on the East and West coasts is Meridian Health Care Management, which has offices in California and Pennsylvania. Kevin Krause, executive vice president in the IPA development and management company's Pennsylvania office, says Meridian is building business there, currently serving 65 primary-care physicians and 150 specialists. It serves more than 6,000 physicians nationwide.
If delegated by an HMO, Meridian can perform full-service credentialing, including data verification and on-site physician office visits. It charges physicians between $75 and $150 for the credentialing paperwork and $75 per on-site visit. The physicians are then reimbursed by the health plan requesting the credentialing service.
Meridian's IPA physicians credential themselves on a form developed by the predecessor to the National IPA Coalition that elicits the basic information needed to make a credentialing decision. They then try to get managed-care plans to accept the forms collected from physicians.
As physician groups do more credentialing, private companies are offering computer applications to make the job easier.
Healthcare Credentials Management Services, a subsidiary of Deerfield, Ill.-based MMI Cos., in May launched appSTAT, an online credentialing service.
Company President Mark Kulik says physicians make a one-time investment to complete a comprehensive application that is stored electronically, with the doctor having access to make changes. When a plan seeks information, appSTAT draws the appropriate fields from the database to complete the plan's form.
Plans are charged $250 to load the form. If the plan is not registered with appSTAT, doctors can try to recruit it or submit a generic form.
In a press release announcing its product, MMI estimated the process of providing credentialing information results in 1 million days of wasted time for physicians each year and costs doctors, hospitals and health plans $260 million annually.
Another computer product designed to reduce the time involved is Credentialing Manager, software that references, verifies and stores physical documents such as privileges, licenses, certificates and diplomas. A key feature is the system's ability to scan paper documents that can be used in a Windows environment to "drag and drop" information into their fields.
Henry County Memorial Hospital, New Castle, Ind., was one of the first users of the system, created by Per-Se Technologies, Atlanta. The hospital has used Credentialing Manager to recertify doctors and is starting to use it to track new applications through the credentialing process, says Sandy Jones, a programmer/analyst at Henry County Memorial. "It helps to have the information in the computer rather than in file folders," Jones says.
No matter which credentialing route medical groups take, says MMI's Kulik, improved automation and simplification are crucial as the "demand for verification grows exponentially." He sees the possibility of one or two national databases, similar to what's seen in the financial services industry.
Meridian's Krause says a "national system is probably too simple, but that's the way we should go."
John G. Hope is a Harrisburg, Pa.-based freelance writer.