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:

1. 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.

2. 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    

Dear Dr. Levine:

Community Care Network of Virginia, Inc. (CCNV) is the Commonwealth of Virginia’s only health center controlled network and has served in this role for twenty years. CCNV is in strong support of the Medical Society of Virginia’s public petition for amendment of the provider credentialing and recredentialing regulations found at 12VAC5-408-170 published in the Virginia Register of Regulations on February 8, 2016.

Virginia’s health centers provide care to the medically underserved as well as MCHIP enrollees throughout the Commonwealth. Last year’s data on health center patients reveals that while approximately 40% of the patients were uninsured and 35% were recipients of publicly insured programs such as Medicaid/Medicare, almost a quarter of health center patients are MCHIP enrollees. Virginia’s health centers provided care for 330,000 Virginia residents.

CCNV has many responsibilities that it fulfills on behalf of its network members and one of them is to perform credentialing related activities. Annually, CCNV performs credentialing/recredentialing services for over 350 providers. CCNV’s credentialing and recredentialing activities assure its patients have access to the same high level of quality providers that all residents in the Commonwealth enjoy. CCNV applauds the language in the Certificate of Quality Assurance of Managed Health Care Health Insurance Plan (MCHIP) Licensee regulations found at 12VAC5-408-170 that assure provider quality through the credentialing process. I am familiar with the regulations as I drafted them while they were in their nascent stage. As evidence of my familiarity with the regulations, I invite you to review an article I wrote about them that was published in the Virginia State Bar’s Health Law Section newsletter entitled, “Inside the MCHIP Regulatory Process”. The article can be accessed at https://www.vsb.org/sections/hl/HLN-2001-2.pdf.

CCNV has reviewed the Medical Society of Virginia’s proposed changes in the regulations in great detail. CCNV concurs with each suggested change as they promote the ability for quality network providers to begin caring for patients in Virginia with all deliberate speed. The ability to have providers begin to see patients at the time they are credentialed assures true network adequacy. Network adequacy is severely compromised if the MCHIPS are able to identify providers in certain geographic areas who are on the MCHIP list as being credentialed but are not able to care for patients because the providers have not been officially “enrolled” into the MCHIP automated system. The amount of time it takes to have providers enrolled in MCHIP automated systems often prevents certain geographic areas, particularly rural areas, from benefitting from having an adequate number of providers to care for the enrollees who are paying for the MCHIP products.

In closing, CCNV strongly concurs with the changes proposed by the Medical Society of Virginia and encourages the proposed amendment as identified. Please feel free to contact me if you have any questions.

Sincerely,

Rene S. Cabral-Daniels, JD, MPH

CEO, Community Care Network of Virginia, Inc.

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