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The Realities of Credentialing in Healthcare Providers vs. Commercial Plans for Network Approval

The Realities of Credentialing in Healthcare Providers vs. Commercial Plans for Network Approval

Yesterday, my association’s message board was buzzing with an intriguing conundrum presented by a colleague. This owner of a revenue cycle management company is entangled in the labyrinth of Blue Cross’ credentialing process.  The timelines offered are absurd. And sadly, real.

The Lengthy Wait for In-Network Healthcare Credentialing

And speaking of realities, let’s dive into the elephant in the room. The amount of time it takes for any provider, be it a heart healer, a mental health healer, or a substance use disorder facility to become an in-network provider is nothing short of egregious.  Brace yourselves for this shocker: many payers now consider a whole year as the standard waiting period for credentialling.  In a world where out-of-network coverage is often akin to finding a needle in a haystack, how do they expect businesses to survive?

Intriguing Revelations and Patient-Physician Ratios

Intrigued by this madness, I decided to investigate further and stumbled upon a shocking revelation in Palm Beach County. Brace yourself again!  The ratio of patients to physicians for primary care providers is a jaw-dropping 1,260:1. As if that weren’t alarming enough, the national average is 1,310:1. You’d think that payers would race against the clock to ensure they have a robust network of providers. But alas, that’s wishful thinking!

Legal Battles and Bureaucratic Mazes

Thankfully, some brave souls have taken the battle to the courts with class action suits against these payers. However, we can’t exactly hold our breath for a speedy resolution. So, my fellow healthcare warriors, what can we do to face this bureaucratic maze and emerge victorious?

As providers, third-party partners, and loyal customers of these health plans, we must unite and navigate these choppy waters together.  In the realm of healthcare, the struggle between healthcare providers and health plans over in-network approval has reached a critical point. This issue has raised concerns about patient care, provider reimbursement, and overall healthcare system efficiency.

Access Dilemmas: Patients, Providers, and Network Challenges

Healthcare providers often face significant delays in getting approved as in-network providers with various health plans. This means they cannot offer services to patients who are members of those health plans. Thus, leading to restricted access to care. On the other hand, health plans often decline out-of-network coverage, resulting in additional challenges for patients seeking care from providers not yet in-network. This tug-of-war between providers and health plans poses serious consequences for all parties involved. People die waiting.

Ironically, just this month, Atlanta News First reported on a class action lawsuit targeting a health marketplace plan for not having enough providers in network for the patients to see.

The article goes on to state that Atlanta News Investigates reached out to 27 primary care providers in Midtown Atlanta listed as in-network on Ambetter’s site. Of the 18 providers that responded, seven said they did not take the insurance at all. Six replied they’re not taking new Ambetter patients, or it depends on the specific plan. Five confirmed they do accept Ambetter.  (Remember the odds of PCP to patients I mentioned earlier?)

Identifying Causes of Credentialing Challenges

We don’t have to think very hard to identify the causes of the problems:

  1. Inadequate Communication: Lack of efficient communication channels between providers and health plans leads to delays in the credentialing process. This can be due to bureaucratic inefficiencies or a high volume of applications.

  2. Complex Credentialing Process: The process of becoming an in-network provider can be highly intricate. It involves multiple steps such as verification of qualifications, licensure, background checks, and documentation. This complexity leads to longer wait times.

  3. Provider Shortages: Some regions may already be experiencing a shortage of healthcare providers. This exacerbates the problem of limited access to care.

  4. Negotiation and Reimbursement Disputes: Providers may hesitate to join certain health plans due to concerns about fair reimbursement rates. Similarly, health plans may be reluctant to include providers in-network if they demand higher reimbursement rates.

  5. Lack of Transparency: Providers often find it challenging to get detailed information about the status of their application or the reasons for rejection. This leads to confusion and frustration.

Seeking Solutions: A Path Forward

In an ideal scenario, solutions should be implemented promptly and with utmost efficiency. Before delving into potential remedies, I would like to commend Anthem GA for its proactive (perhaps mandatory) yet highly efficient approach. Towards the end of last year, we encountered another prolonged credentialing process with an outpatient clinic. Out of sheer frustration, I decided to reach out to a Vice President on LinkedIn, fully aware of the challenging odds. Surprisingly, he responded and informed me that Anthem GA already had a dedicated “Resolution Team” prepared to address such issues. In just over a month, the clinic’s credentialing was completed appropriately, enabling us to proceed with claims submissions. I extend my sincere appreciation to Anthem GA for their exceptional efforts in resolving this matter. I also learned that California has placed a mandatory 60 business days for credentialing, and it isn’t being followed.


The solutions below aren’t scientific. I suspect they are already on the table at some of these payer’s board meetings. What needs to drive this are the members. The members, why? Because regardless of how much mitigation a donation can sway, if consumers do not buy, then the healthcare plans go bye.  But then what?

  1. Streamline the Credentialing Process: Health plans should work on simplifying and expediting the credentialing process for providers. Implementing a standardized and transparent system will reduce delays and minimize bureaucratic obstacles.
  2. Improved Communication Channels: Both providers and health plans need to establish better communication channels to address concerns, provide updates, and resolve issues promptly.
  3. Incentives for Health Plans: Introduce incentives for health plans to prioritize the onboarding of new providers into their networks. This could include faster processing times or financial benefits for promptly approving qualified providers.
  4. Mediation for Negotiation Disputes: Create an independent mediation body to address reimbursement disputes between providers and health plans. This will ensure fair negotiations and encourage more providers to participate in networks.
  5. Temporary Out-of-Network Coverage: While providers are waiting to become in-network, health plans could consider offering temporary out-of-network coverage for patients, reducing barriers to access during the waiting period.
  6. Telehealth Expansion: Promote telehealth services, allowing patients to access care from a broader range of providers regardless of their in-network status.
  7. Increasing Provider Capacity: Invest in programs to increase the number of healthcare providers, particularly in areas facing shortages, to improve overall access to care. – But they need to be compensated fairly and promptly, not wait six months for a check.

A Call for Improved Access and Collaboration

The prolonged waiting period for providers to become in-network with health plans, coupled with the denial of out-of-network coverage, is a significant challenge for both patients and healthcare providers. By streamlining the credentialing process, improving communication, and addressing reimbursement disputes, the healthcare industry can take steps towards resolving this issue and enhancing patient access to quality care.

Collaboration between providers, health plans, and policymakers is essential to implement these solutions and create a more efficient and patient-centric healthcare system.

Denise Corbisiero

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