Marissa Levine, MD, MPH
State Health Commissioner
Virginia Department of Health
109 Governor Street
Richmond, Virginia 23219
RE: Public Petition for Amendment of 12VAC5-408-170: Provider credentialing and
recredentialing.
Dear Dr. Levine:
I write on behalf of Patient First in support of the petition for rulemaking filed by the Medical Society of Virginia (“MSV”) and published in the Virginia Register of Regulations on February 8, 2016 (the “Petition”). MSV has petitioned for amendment of Title 12 VAC 5-408 (Certificate of Quality Assurance of Managed Care Health Insurance Plan Licensees) and specifically of Section 170: Provider Credentialing and Recredentialing (the “Credentialing Regulations”).
Patient First supports the changes proposed in the petition and urges you to consider it favorably. We believe the Petition offers a worthy first step to improve the fairness and efficiency of provider credentialing in the Commonwealth.
In addition, we urge the Department to consider additional future modifications of the Credentialing Regulations, again to address inequities in current Virginia payor credentialing procedures. Specifically:
Patient First strongly urges the Department to amend the Credentialing Regulations to cause a provider for whom a complete and accurate application has been submitted to be deemed to be credentialed ninety (90) days after the submission date.Under the Petition, a MCHIP licensee is required to “complete the credentialing process” by such date but there is no sanction available if it does not.
Deemed status is critical to the proper function of the new paragraph F that will be added by the Petition. Paragraph F provides, in part, that a MCHIP licensee shall pay a provider as a participating provider from and after the date on which he or she is approved by the licensee’s credentialing committee. Absent deemed status on the 90th day following submission, there is no incentive for MCHIP licensees to cause their credentialing committees to act on applications within the required 90 day period. It is a critical omission to the proposals contained in the Petition, and we urge the Department to close the loophole in the near future.
The Petition makes no amendment to require MCHIP licensees to be ready to process claims submitted by a credentialed provider at the end of the 90 day approval period.Patient First routinely encounters MCHIP licensees that approve a physician to participate in their contracts but do not “load” them into the MCHIP licensees’ billing and claim submission systems for weeks or months thereafter.The result is denied claims, payment delays and – often – payment denials.The Credentialing Regulation should require MCHIP licensees to take all steps necessary to be ready to pay for claims submitted by a participating physician on the date that he or she is approved for participation.
Patient First provides urgent and primary care medical services at 27 locations in the Commonwealth of Virginia. Our medical centers are open from 8 a.m. to 10 p.m. every day of the year, and will treat patients during more than 1.1 million visits in 2016.
Thank you for giving us the opportunity to comment on the Petition. Please call me at (804) 822-4388 if you have questions or I may be of assistance.
Sincerely,
John Sharp
Senior Vice President, Market Development