Credentialing physicians is frequently an arduous process that takes several months to complete and involves hours of paperwork detailing every certification, academic experience and personal background. Thankfully, for Virginia physicians, the Virginia General Assembly made this process less traumatic through a recent change that will allow for physicians to be reimbursed by the carrier while their credentialing applications are pending.

While becoming credentialed with an insurance carrier can lead to a larger patient pool, providers have been at cross-roads while waiting for their credentialing applications to be processed as they cannot bill the carrier for any services they provide during that waiting period. Essentially, a provider must choose between waiting for months to see patients covered under that carrier or potentially suffer a loss on the services. Effective July 1, 2018, the Code of Virginia was amended by adding § 38.2-3407.10:1 to address this concern. Under this new rule, if a contractual relationship exists between the carrier and the physician group (or entity for whom the physician is employed or engaged), the new physician may be reimbursed for services he or she renders starting from the date the physician’s completed credentialing application is received for consideration by the carrier. Reimbursements are paid at the in-network rate the physician would have received had they been, at the time the covered health care services were provided, a credentialed participating physician in the network for the applicable health plan.  Claims would be submitted after credentialing is completed.

There are two significant limitations to keep in mind. First, carriers are not required to reimburse for benefits or services that are not covered under their health benefit plans. Second, carriers are not required to reimburse if the new physician’s credentialing application is not approved or the carrier is otherwise not willing to contract with the new provider.

It is also important to note that physicians must take certain steps to ensure compliance with the rule to receive reimbursement. Specifically, the physician must make his or her covered patients aware, through written or electronic notice and in advance of providing treatment, that the provider has submitted a credentialing application to the carrier. Further, the notice should follow the form below and state that the carrier is in the process of obtaining and verifying information on the physician:

Notice of Provider Credentialing and Re-credentialing.

Your health insurance carrier is required to establish and maintain a comprehensive credentialing verification program to ensure that its physicians meet the minimum standards of professional licensure or certification. Written supporting documentation for physicians who have completed their residency or fellowship requirements for their specialty area more than 12 months prior to the credentialing decision shall include:

  1. Current valid license and history of licensure or certification;
  2. Status of hospital privileges, if applicable;
  3. Valid U.S. Drug Enforcement Administration certificate, if applicable;
  4. Information from the National Practitioner Data Bank, as available;
  5. Education and training, including postgraduate training, if applicable;
  6. Specialty board certification status, if applicable;
  7. Practice or work history covering at least the past five years; and
  8. Current, adequate malpractice insurance and malpractice history covering at least the past five years.

Your health insurance carrier is in the process of obtaining and verifying the above information in order to determine if your physician will be credentialed or not.

This regulation change is a significant step towards making the credentialing process easier for physicians. However, regardless of any updates, credentialing remains a complex and lengthy process with numerous challenges. Providers should continue to remain alert for any future changes in the credentialing process.

If you have any questions or need assistance regarding this regulation or other advice on physician credentialing, please contact Hancock Daniel’s Government Relations or Compliance team.

The information contained in this advisory is for general educational purposes only. It is presented with the understanding that neither the author nor Hancock, Daniel & Johnson PC, is offering any legal or other professional services. Since the law in many areas is complex and can change rapidly, this information may not apply to a given factual situation and can become outdated. Individuals desiring legal advice should consult legal counsel for up-to-date and fact-specific advice. Under no circumstances will the author or Hancock, Daniel & Johnson, PC be liable for any direct, indirect, or consequential damages resulting from the use of this material.

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