Virginia General Assembly Improves Credentialing

Managing provider enrollment applications can be overwhelming. The data collection process can be incredibly fragmented and numerous payers impose unique requirements to create a network of delays. But there are some signs of relief, not only with new cloud-based workflow applications but with new regulations too.

The General Assembly of Virginia recently amended the state code to allow for reimbursement for services rendered during pendency of a physician's credentialing application.  Now a Virginia provider may be reimbursed for services provided from the date a complete credentialing application is submitted through the date of approval.  Specifically, the Code of Virginia was amended by adding a section numbered 38.2-3407.10:1 as follows……:

1. A carrier that credentials the physicians in its network shall establish reasonable protocols and procedures for reimbursing new provider applicants, after being credentialed by the carrier, for health care services provided to covered persons during the period in which the applicant's completed credentialing application is pending. At a minimum, the protocols and procedures shall:
2. Apply only if the physician's credentialing application is approved by the carrier;
3. Permit physician reimbursement for services rendered from the date the physician's completed credentialing application is received for consideration by the carrier;
4. Apply only if a contractual relationship exists between the carrier and the physician or entity for whom the physician is employed or engaged; and
5. Require that any reimbursement be paid at the in-network rate that the physician would have received had he been, at the time the covered health care services were provided, a credentialed participating physician in the network for the applicable health benefit plan.

Of course, a labyrinth of other rules applies to the effective date of commercial carriers in other states, but we applaud the Virginia general assembly for taking a step in the right direction.  The credentialing process is changing but automation and efficiencies still require a knowledgeable, dedicated, and proficient staff.

New Bedford has been credentialing providers for 25 years and is able to combine the latest workflow technology with a credentialing department knowledgeable of every payer and state. Try us for your next enrollment and let us show you how much better things can be.