The largest credentialing IPA in the Midwest, Primoris Credentialing Network, has entered the Illinois market. Primoris currently accepts applications for credentialing from healthcare providers in the Prairie State.
The Illinois expansion was not a solo effort. Anders CPA + Advisors, a trusted partner of Primoris and the Fifth Avenue Healthcare Services family of companies, helped the credentialing IPA gain footing in the new market.
Anders CPA + Advisors offers tax counseling to large and small businesses among its many services. Anders CPA + Advisors can also assist providers in getting their licenses after they finish the complex credentialing and provider enrollment processes.
Primoris Credentialing Network has long been the one solution providers think of when they need quick credentialing solutions. The provider enrollment experts offer 54+ health plan and network enrollment options, with many more on the way.
The Delegated Credentialing Illinois Market
Delegated credentialing for Illinois is the smarter way to complete credentialing and the simplest. Primoris has delegated contracts with payors and networks across Illinois, Missouri, and the Midwest, serving 1000s of providers who want to begin billing now.
We specialize in delegated credentialing. Using one application to add a provider to multiple health plans and networks can save time, meaning more revenue for providers. We can complete the process approximately 75 days faster than the industry average of 90 to 120 days. Providers and their practices can acquire up to $707,954 in new billing opportunities.
Delegated credentialing Illinois payors include:
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- MultiPlan: a national healthcare cost management company.
- Prime Health Services: supplies healthcare cost containment and medical management services to the group health, workers’ compensation, corrections, and auto liability markets.
- USA Managed Care Organization: the largest privately-held Preferred Provider Organization in the United States.
We aim to have every plan in the Illinois market be eligible for Primoris delegated credentialing. We look forward to partnering with Aetna, Humana, American Health Advantage of Missouri, United Healthcare, and 17 other plans.
Exploring Delegated Credentialing
The National Practitioner Data Bank defines delegated credentialing as “when a health care entity gives another health care entity the authority to credential its health care practitioners.”
Delegated credentialing’s primary benefit is that it can get providers to work faster so they can begin billing. The process also ensures accuracy and oversight than other credentialing operations. Additionally, reimbursements from payors can happen faster, increasing provider satisfaction. Delegated credentialing can also reduce labor, supplies, and the turnaround time for network participation.
Delegated credentialing, also known as delegated provider enrollment, is typically a 3-stage process:
- Primary Source Verification of a Provider’s Credentials
- Payor Application Process
- Contracting Process
Below is an overview of each of these stages.
Stage One: Provider Credentialing or Primary Source Verification (PSV)
Primary Source Verification (PSV) is necessary for every healthcare provider seeking to be enrolled in any health plan or network option. Insurance companies do not want unverified providers on their plans, which would present a tremendous risk of financial costs in claims and litigation. Credentialing can identify providers considered unqualified to treat patients, potentially decreasing patient injuries, claims, lawsuits, and even deaths.
Conventional credentialing typically involves 52+ action steps that must occur before a file is ready for presentation.
52 conventional credentialing steps include:
- Sending out, tracking, and receiving the provider application packet.
- Obtaining the provider’s release.
- Getting the privilege forms.
- Reviewing the disclosure’s questions and answers.
- Evaluating the explanations of time gaps and claims history.
- Assessing medical malpractice claims history.
- Acquiring applicable certificate copies of Board, ECFMG, Medical School, Internship, Residency, Fellowship, and two years CME.
- Obtaining copies of government-issued photo ID, Malpractice, DEA, and CDS.
- Getting CPR, ACLS, and PALS certificate copies.
- Acquiring TB, MMR, varicella, and flu vaccination records.
- Attesting any conflict of interest.
- Collecting a provider release and ordering a criminal background check.
- Obtaining an Allied Health Professional’s Supervising Physician’s Statement.
- Verifying Board certification.
- Reviewing and confirming AMA and AOA Profile.
- Authenticating medical school internship, residency, fellowship, and affiliations.
- Confirming state medical licensure.
- Obtaining professional peer references.
- Gathering current medical malpractice claims history.
- Researching primary and out-of-state licenses for disciplinary actions.
- Verifying DEA certification.
- Verifying CDS certification (if applicable).
- Obtaining a copy of the provider’s current certificate of insurance.
- Confirming any Medicare and Medicaid sanctions (OIG) and exclusions (SAM).
- Performing an extensive 10-year criminal background check.
- Running a National Practitioner Data Bank query.
Credentialing alone is a lengthy step in the provider enrollment process. Primoris collaborates with its sister company, 5ACVO, to shorten this step from 52 conventional credentialing steps to 6 simple steps.
Stage Two: Payer Enrollment Plan Application
Each health plan, including Medicare, has its application process. Like enrollment policies, applications can vary based on state, health plan, network, and area of practice. Learning how to apply with any payor can be frustrating and time-consuming. Applying to multiple payors per provider can drain resources, time, and energy and increase costs that could be better spent on helping patients or running a provider’s practice.
Primoris can aid providers through this crucial stage by fully administering the application process and applying to 25+ delegated health plans and networks via ONE application. Another 25+ non-delegated health plan and network options allow providers to begin billing and see patients sooner than the traditional application process.
Delegated contracts allow Primoris to use ONE application to enroll a provider much faster than the traditional method of sending an application to each health plan.
Stage Three: Contracting
After the primary source verification and plan application stages, the plan sends a contract to the provider to review and sign. Once the provider approves the terms and signs the contract, the plan countersigns the agreement. When contracting is complete, the plan completes the loading process and sets a date for the provider to begin accepting covered patients and billing.
The same general process is repeated for each payor, including Medicare and Medicaid. Having someone with experience aid the provider in the Medicare and Medicaid application process is helpful. Medicare enrollment can be elaborate and lengthy. Simple mistakes can be costly and delay enrollment and billing.
Outsourcing Delegated Credentialing
When you let us perform your delegated credentialing, we can:
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- Reduce credentialing and enrollment mistakes.
- Reduce staff and resource impacts.
- Reduce costs.
- Give you and your patients peace of mind.
- Get you billing sooner via our delegated contracts.
Delegated contracts facilitate faster enrollment than the traditional method of applying each plan.
Our delegated health plan provider enrollment options include the following:
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- GlobalHealth: an HMO/SNP HMO plan with a Medicare contract and a state Medicaid contract for D-SNP.
- Healthcare Highways: offers market-tailored solutions to deliver quality care and cost savings.
- HealthSmart: one of the largest third-party administrators in the United States and provider of personalized health plan solutions for self-funded employers.
- Longevity Health Plan: a specialized Medicare Advantage health plan for people in skilled nursing facilities.
- Medica: a health plan serving 1.5 million people.
- Oklahoma Complete Health: a Managed Care Organization that strives to improve the health of its beneficiaries.
- Sedgwick: provides risk, benefits, and integrated business solutions.
- And More
Our Non-Delegated Contracts
We gladly handle all the duties required to complete non-delegated contract work. Our long histories with our non-delegated health plans and networks can expedite credentialing and provider enrollment.
We are proud to work with the following:
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- Indian Health Services: “The Federal Health Program for American Indians and Alaska Natives.”
- Integris Health: Oklahoma’s largest not-for-profit health care system.
- Medicare: The United States national health insurance program.
- Oklahoma Health Care Authority: Oklahoma’s state-level counterpart to Medicare.
- Preferred Community Choice PPO: a partnership between Saint Francis Hospital and St. John Medical Center in Tulsa, Oklahoma, that serves 1000s of members.
- Tricare: provides care for uniformed service members, retirees, and their families worldwide.
- TriWest Healthcare Alliance: administers health care to the military and Veteran communities.
- And Many Others
Whether you wish to enroll in delegated or non-delegated contracts, we will work to get you credentialed and enrolled as swiftly as possible.
More Contract Options to Come
We always want to expand our contract offerings, giving you more billing opportunities. Not only have we expanded into the Illinois market, but we have also entered the Missouri market.
We work hard to add health plans and network options to our extensive provider enrollment options. Our credentialing and provider enrollment team must pass strict audits whenever we want to begin and renew a contractual relationship. We expect to receive and pass at least one delegated oversight audit annually.
These audits help ensure we properly credential providers and comply with payor and accreditor regulations. We are proficient in adhering to certifying body standards, data management technology security, information handling policies, and roster quality.
We passed a HealthSmart audit in December 2021, scoring 100% in every area we were assessed. We passed a MultiPlan audit in March 2022, meeting all the requirements for credentialing, re-credentialing, appeals, monitoring, provider rights, and system controls. Our administrative simplicity continues to serve our members and us well.
How Administrative Simplicity Works For You
Administrative simplicity is the primary ingredient in our delegated credentialing. Our members can begin to treat patients sooner and start billing quicker than the industry average. It is our streamlined method of offering faster, cheaper, and better provider enrollment.
Administrative simplicity of the credentialing process includes:
- ONE Provider Enrollment Application. You do not have to fill in and submit an application to each health plan and network you want to join. Our administrative simplicity cuts your workload, giving you one application to manage. Less work means less time until you are enrolled and billing.
- ONE Proficient Provider Enrollment Team. Our team has 385+ years of combined industry experience. Their expertise has helped us become the largest credentialing IPA network in the Midwest. Their knowledge and dedication have led them to develop and perfect the provider enrollment process.
- ONE Credentialing Ecosystem. We take data privacy seriously. You do not have to worry about who can access your information. Your data will rest in a secure ecosystem. Locking file cabinets and securing loose paperwork can become things of the past. Each piece of your data is logged and stored in our system.
- ONE Delegated Credentialing Web Portal. Our Delegated Credentialing Web Portal offers our member providers accessibility and functionality. Providers can easily and quickly access all of their credentialing data files. All it takes is one login to reap the benefits of organized and secured data. Members can access the Web Portal whenever they want from any device. They can connect with their information as long as they can connect to the Internet.
- ONE Point of Contact. We know how tight your schedule can be. You may need more time to track down someone to find the underlying cause of your provider enrollment status. We want to make your job less stressful. We can offer you one point of contact for your credentialing and provider enrollment needs. If you need help, you only need to keep track of one email address and one phone number.
- Simple Fixed Costs. We believe in transparency, especially when it comes to expenses. When you let us oversee your delegated credentialing, your costs become fixed. No hidden fees will surprise you. Teaming with us can help you overcome financial issues like employee training and turnover. You will know what you will be paying for.
A Look at Our Delegated Credentialing Web Portal
We recognize how essential strong data privacy and protection are in health care. Data security protects our reputation and the data we manage. Providers can trust that we respect their security wishes. Our Delegated Credentialing Web Portal was built with security and accessibility in mind.
You can use the credentialing web portal to:
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- Access your providers’ credentialing progress, your group’s health plan enrollment status of sent and received applications, and historical and current rosters.
- Create and view reports for all your files, including historical rosters and expirables.
- Customize logins for administrators.
- Track essential information like current statuses, updates, credentialing files in progress, reappointment filings, historical files, expiring documents, and committee dates.
- Upload and save your documents in your customized e-filing cabinet.
- Update rosters, change health plan enrollment requests, order new files, cancel files in the process, and more.
More Perks, Less Paper
Our Delegated Credentialing Web Portal gives providers and administrators speed, accessibility, control, and visibility. They no longer have to wonder if their applications were submitted or who can log into their account. They can dive deep into the credentialing process by signing into the portal.
Our cloud-based solution offers our members yet one more benefit. Providers and their practices can cut the amount of paper they normally use when they perform in-house credentialing and provider enrollment. Saving money on supplies can come in handy when it is budget time.
Less paperwork can also mean fewer lost, stolen, or damaged documents that could delay providers from billing. The office staff does not have to hurry to print new forms to process when they upload everything to the credentialing web portal. Although provider data and activity will sit in our online ecosystem, everything can access anytime and anywhere on any device. You can review, download, and email what you need whenever you want. All you need is an Internet connection to stay on top of things.
Changing the Delegated Credentialing Landscape
Entering the Illinois market is just one more step towards us becoming the only delegated credentialing solution you think of when you need to enroll in health plans and networks. Our plan options, administrative simplicity, and secure web portal are changing how providers view delegated credentialing.
More information about Primoris Credentialing Network
Primoris Credentialing Network is NCQA Credentialing Accredited specializing in credentialing and provider enrollment with 54+ health plan and network provider enrollment options. Primoris is a family member of Fifth Avenue Healthcare Services. Sister companies include 5ACVO (credentialing and primary source verification specialists) and Fifth Avenue Agency (MPLI and medical malpractice specialists).
Primoris Credentialing Network originally published this article here. For more information on Primoris, please visit PrimorisCredentialingNetwork.com or Contact Us.
