PPO White Paper Series

Why does your organization credential providers?
Quality.
Credentialing our providers provides assurance to our payor sources that PREFERRED is recruiting only the most qualified physical, occupational, and speech therapy practitioners; particularly with so many rehabilitation companies utilizing technicians, massage therapists and physical therapy assistants. In addition, our credentialing process allows us to understand the specific skill sets of our providers and address previous issues or licensing concerns.

Please describe the basic process you use to credential?
There are three basic steps to our credentialing process.
Step One:
The provider is sent a comprehensive application and must supply information on education and training, work history, state licensure or certification, liability insurance information, liability claims history and references. They must also supply any history of adverse actions taken against the applicant and sign a release of information as well as sign a waiver that the information supplied is truthful, complete and correct.
Step Two:
The verification of critical elements is performed by our Credentialing Department, following the national guidelines set forth by NCQA. These include: National Board Certification, State Licensure, Medicare/Medicaid Sanctions, National Practitioner Databank (NPDB) Query, Highest Level of Professional Degree, Malpractice Insurance Coverage, Malpractice History (five year), any work gaps of six months or greater in the Practitioner work history over the past five years.
Step Three:
Each practitioner is presented to the Credentials Committee for evaluation and approval.

Do you recredential providers, and what are the steps in that process?
Yes, recredentialing ensures continued quality of our network, and identifies any changes that may have occurred since the last credentialing process. Our providers are recredentialed every three years, except in those states with a mandated two year recredentialing cycle. We use the same basic process to recredential our providers as we do to credential them. We also perform annual, in-house Base Credentialing which includes an audit of all required documents on file and gathering documents such as current licensure and malpractice insurance.

What is the value of credentialing to your organization?
The value of credentialing to our organization is two-fold. First, an effective credentialing process ensures the payor community that PREFERRED is able to successfully select and retain qualified health care providers who will, in turn, provide quality services. Secondly, a reputable rehabilitation professional will want to associate with a network that has high selection standards. Reputable providers tend to appreciate a proper credentialing process that is done efficiently and timely because a network that engages in a thorough credentialing process attracts more healthplans, thus increasing a provider’s patient base.

What elements of your organization’s process would you say are innovative or particularly valuable?
Unquestionably, one of the most valuable elements of our Credentialing and Recredentialing process is PREFERRED’s credentialing committee. Our Credentialing Board is comprised of exceptional Physical and Occupational therapists, all of whom are volunteers. Utilizing a peer review process, they are responsible for the final decisions for our credentialing and recredentialing. We believe that PREFERRED’s credentialing committee adds validity to the system by including technical knowledge that may not otherwise be available to PREFERRED. Such advice helps ensure that procedures are followed consistently. Participating practitioners bring expertise on current practices in the therapy community and provide advice on modifying the criteria, as appropriate.

In general, what do you think are some innovative practices in credentialing (whether or not your organization has adopted them)?
I think that would have to be Automation of Processes. Internet technology has provided the capability to verify a provider’s credentials literally at the touch of a button. There is online access to JCAHO, NCQA, URAC, and other healthcare accreditation agencies. Providers are able to download forms, send and receive information via email or facsimile. There is capability for virtual paperless systems as images can be scanned and files can be stored in secure sites. We have truly come a long way in the terms of innovation practices and credentialing over the past several years and continuous improvements for access to information and how this information can be stored is an ongoing process.

In general, what aspects of credentialing do you think could or should be improved?
Constantly, we hear talk about “streamlining” the credentialing process and cutting costs, yet at the same time we, as consumers, demand an increased focus on the quality of care. At PREFERRED, we have a high standard of quality assurance and with that standard we employ high standards of quality control. With that being said, I think that one of the most critical aspects of improving any credentialing process is to develop a sound management structure, and to employ audit and monitoring processes, so that your focus is to continually improve the quality of the services delivered.