Health Insurance and Providers
Posted by Sheri Harris on Thursday, July 14, 2011
Under: Problems and Solutions
Problem
There are many different types of health insurance available today. Credentialing for them is not always easy. First, there are forms to fill out and contracts that the doctor has to sign. The ususal repetitive information is asked and each insurance application requires the typical documentation of certificate, licence and resume although some sophisticated two word phrase is used to describe it- are these people really worth it? After the assembly printout of all paper requirement is completed the packets are sent to the respective insurance companies for processing and ultimate approval. Strangely enough, there is a credentialing database that is supposed to be the collection mechanism for all of this information so that people who are asked to gather such information for their employer can just submit it to this one database. Why does this not work? It seems as though the employee's that do this sort of thing are saying "tomato", and the insurance companies are saying "tomatoe". Now there is a conflict because these databases are sometimes looked upon as fruit when others see them as a vegetable. When this occurs the whole meal is disrupted. Why? Because if the credentialing database is designed to take in all the "tomatos" including the certificates, resumes, licences ect, then in effect that database is the vegetable behind all insurance credentialing. Once that is established then the insurance company shall bear fruit from going to the credentialing database to obtain all the information necessary so that medical providers can begin accepting insurances because these companies have all the information for them to do so. The way things are done now is like going to the rexograph room or something (1970's era) to make copies to give to everyone. It is a waste of time, paper ect. This system is hardly user friendly and very ineffective. Health insurance provider reps often times do not keep in contact with the area or territory they are supposed to cover and make visits or contact the physician so that if there are any problems or issues that a physician needs to do to remain a participating provider those situations can be addressed. It would be great as an introduction and then afterwards the health insurance provider representative should update contact information if something changes. Regarding the tomato and tomatoe aspect, everything is understood and the physician can now be reimbursed because they are considered a participating provider. Insurance companies fail to do this and should make their presence known if they wish to keep providers participating. Or is this just a shisty way of having providers charge out of network because they are not considered participating? If so, since the insurance company will not pay then the cost goes to the patient. Given such outcome the difference between tomato and tomatoe will become evident by tomato puree-skimpy meals!
Solution
Credentialing databases need to become the tomato of the health insurance industry by requiring that all pertinent information needed by an insurance company in order for a physician to be considered for participation be submitted to them. Once this information is recieved and the database regarding the physicians information is complete. The "paper work" ie. the certificates, licences, malpractice information once scanned can be viewed for any and all information needed by an insurance company. All the insurance company needs to do is use the physician assigned credentialing database identifier or number to access a physicians credentials on the credentialing database. This would mean that once all of the information is complete the provider may just have to sign a contract or two and provide basic address and phone contact information along with tax id, npi and credentialing database id. After that is completed it is up to the insurance company to obtain provider information through the credentialing database and the physician or employee must update the database with current certificates, licences, malpractice information as they are renewed. This credentialing database can also be used by insurance companies to contact a provider in regards to information that is needed or to update information so that a provider remains participating. Stop crushing on the tomatos- use the credentialing databases as this is the way they should be used and by having the insurance companies stay in contact with their providers! If you don't do this you are essentially canning them!
There are many different types of health insurance available today. Credentialing for them is not always easy. First, there are forms to fill out and contracts that the doctor has to sign. The ususal repetitive information is asked and each insurance application requires the typical documentation of certificate, licence and resume although some sophisticated two word phrase is used to describe it- are these people really worth it? After the assembly printout of all paper requirement is completed the packets are sent to the respective insurance companies for processing and ultimate approval. Strangely enough, there is a credentialing database that is supposed to be the collection mechanism for all of this information so that people who are asked to gather such information for their employer can just submit it to this one database. Why does this not work? It seems as though the employee's that do this sort of thing are saying "tomato", and the insurance companies are saying "tomatoe". Now there is a conflict because these databases are sometimes looked upon as fruit when others see them as a vegetable. When this occurs the whole meal is disrupted. Why? Because if the credentialing database is designed to take in all the "tomatos" including the certificates, resumes, licences ect, then in effect that database is the vegetable behind all insurance credentialing. Once that is established then the insurance company shall bear fruit from going to the credentialing database to obtain all the information necessary so that medical providers can begin accepting insurances because these companies have all the information for them to do so. The way things are done now is like going to the rexograph room or something (1970's era) to make copies to give to everyone. It is a waste of time, paper ect. This system is hardly user friendly and very ineffective. Health insurance provider reps often times do not keep in contact with the area or territory they are supposed to cover and make visits or contact the physician so that if there are any problems or issues that a physician needs to do to remain a participating provider those situations can be addressed. It would be great as an introduction and then afterwards the health insurance provider representative should update contact information if something changes. Regarding the tomato and tomatoe aspect, everything is understood and the physician can now be reimbursed because they are considered a participating provider. Insurance companies fail to do this and should make their presence known if they wish to keep providers participating. Or is this just a shisty way of having providers charge out of network because they are not considered participating? If so, since the insurance company will not pay then the cost goes to the patient. Given such outcome the difference between tomato and tomatoe will become evident by tomato puree-skimpy meals!
Solution
Credentialing databases need to become the tomato of the health insurance industry by requiring that all pertinent information needed by an insurance company in order for a physician to be considered for participation be submitted to them. Once this information is recieved and the database regarding the physicians information is complete. The "paper work" ie. the certificates, licences, malpractice information once scanned can be viewed for any and all information needed by an insurance company. All the insurance company needs to do is use the physician assigned credentialing database identifier or number to access a physicians credentials on the credentialing database. This would mean that once all of the information is complete the provider may just have to sign a contract or two and provide basic address and phone contact information along with tax id, npi and credentialing database id. After that is completed it is up to the insurance company to obtain provider information through the credentialing database and the physician or employee must update the database with current certificates, licences, malpractice information as they are renewed. This credentialing database can also be used by insurance companies to contact a provider in regards to information that is needed or to update information so that a provider remains participating. Stop crushing on the tomatos- use the credentialing databases as this is the way they should be used and by having the insurance companies stay in contact with their providers! If you don't do this you are essentially canning them!