Tessa Quinn
Insurance companies play a significant role in shaping healthcare delivery and patient experiences. One of the critical aspects of their influence is the requirement for healthcare providers and facilities to obtain insurance credentialing. This process involves registering providers through specific insurance carriers, with the ultimate goal of becoming in-network with the insurance company. While it varies depending on the company and existing contracts, the credentialing process can take up to 120 days and includes gathering and verifying provider information, such as education, work history, licenses, and references. Accreditation, which indicates a hospital's commitment to quality and safety, is often a prerequisite for insurance credentialing. Medicare, for instance, requires accreditation for reimbursement, and hospitals seek to maintain their accreditation to avoid a lapse in Medicare reimbursement. This dynamic between insurance companies and healthcare providers raises important considerations about the accessibility and quality of care patients receive, shaping the landscape of the healthcare industry.
| Characteristics | Values |
|---|---|
| Purpose of accreditation | Assurance of high-quality, safe care |
| Accreditation as a requirement | Yes, for reimbursement of Medicare claims |
| Accreditation as a competitive advantage | Yes, for attracting talented staff and patients |
| Accreditation as an indicator of commitment to quality and safety | Yes, for healthcare professionals choosing a place to practice |
| Accreditation standards | Emphasize structure and process features of hospital organization and administration |
| Medicare reimbursement requirement | Suppliers of advanced diagnostic imaging (ADI) services must be accredited by a designated organization |
| ADI procedures | Include MRI, CT, and nuclear medicine imaging |
| Exclusions from ADI procedures | X-ray, ultrasound, fluoroscopy, and diagnostic and screening mammography |
| Medicare and Joint Commission standard-setters | Mandate quality assurance processes in hospitals |
| Role of survey agencies | Involved in investigations of hospitals where quality indicators signal possible issues |
| Compliance with Conditions of Participation (CoPs) | Prerequisite for payment from Medicare and Medicaid programs |
| Voluntary accreditation | Provides assurance of hospital compliance with standards and regulations |
| Information required for insurance credentialing | Provider's tax identification number, practice locations, billing procedures, and malpractice and liability insurance |
| Time required for insurance credentialing | Typically 90 to 120 days |
| Steps in insurance credentialing | Gather provider information, review and sign payor agreement, begin in-network coverage |
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What You'll Learn
Insurance credentialing
During the credentialing phase, providers submit a participation request to the health plan using their credentialing application process. This may involve the completion of a unique credentialing application, use of CAQH, or acceptance of a state standardized credentialing application. Once the health plan receives the application, they perform a thorough verification of the provider's credentials to ensure they meet their requirements. When all verifications are complete, the credentialing file goes to the Credentialing Committee for approval.
The contracting phase of enrollment occurs when the provider has been approved by the Credentialing Committee and is offered a contract for participation. Most commercial insurance networks have staff dedicated to the contracting process. During this phase, the provider reviews the contract language, reimbursement rates, and all the details and responsibilities of participation before signing the agreement. The provider can also negotiate rates if the standard reimbursement rates are unsatisfactory. Once the agreement is signed and returned, the provider is given an effective date and provider number, allowing them to begin billing the plan and receiving "In-Network" reimbursement for their claims.
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Accreditation as a competitive advantage
Accreditation is a requirement for reimbursement of Medicare claims. Compliance with the Medicare Conditions of Participation (CoPs) is a prerequisite for payment from the Medicare and Medicaid programs, which constitute nearly 60% of hospital costs. Accreditation is one of the paths hospitals can take to be declared in compliance with the CoPs. Thus, accreditation is an important competitive advantage for hospitals.
Voluntary accreditation is considered a symbol of a hospital's commitment to high-quality, safe care. Consumers often look for accreditation when choosing a hospital, and healthcare professionals believe it is an important indicator of the commitment to quality and safety they seek when choosing a place to practice. Accreditation can help hospitals attract talented staff and patients. For hospitals, it is more of an expectation than a distinction, with more than 80% of hospitals receiving voluntary accreditation from one of four recognized accrediting organizations: The Joint Commission, Healthcare Facilities Accreditation Program (HFAP), Det Norske Veritas (DNV), and Center for Improvement in Healthcare Quality (CIHQ).
Accreditation provides assurance to boards and others overseeing healthcare delivery organizations that the hospital is in compliance with current standards and regulations. It also provides a source of information about areas where additional attention or investment of resources may further enhance the safety and quality of care. Boards should understand the range of organizations that oversee hospital performance as part of their oversight responsibilities for compliance, care quality, safety, and stewardship of hospital resources.
The process of insurance credentialing, where a healthcare organization registers a provider through specific insurance carriers or government payers, is essential for receiving reimbursement for medical services. Healthcare providers must complete the insurance credentialing process to become "in-network" with the insurance company and receive reimbursement for services rendered during a patient's visit. The insurance credentialing process typically takes 90 to 120 days and involves gathering and verifying the provider's information and credentials, such as education, work history, licenses, and references. After completing the process, the provider is affiliated with the insurance company and can request payment.
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Federal protections for out-of-network bills
The No Surprises Act (NSA) is a federal law that protects consumers from surprise medical bills. A surprise medical bill is an unexpected bill from an out-of-network provider or facility. The NSA came into effect on January 1, 2022, and offers several protections for consumers with health insurance.
Firstly, the NSA limits the amount consumers have to pay out of pocket for out-of-network charges. This limit is based on a recognised market amount or qualifying figure, such as the average fee for the service, and is typically calculated using the insurance plan's co-pay and cost-sharing percentages.
Secondly, the NSA prohibits balance billing for certain services. Balance billing occurs when an out-of-network provider bills the patient for the difference between the billed charge and the amount covered by the patient's health insurance plan. The NSA bans balance billing for emergency services, as well as for certain additional services such as anesthesiology or radiology furnished by out-of-network providers as part of a patient’s visit to an in-network facility.
Thirdly, the NSA establishes an independent dispute resolution process for payment disputes between health plans and providers. This process is available to both insured and uninsured individuals and allows them to resolve disputes over unexpected or excessive medical bills.
Fourthly, the NSA requires healthcare providers and facilities to disclose billing protections and patient rights to their patients. This includes providing an easy-to-understand notice explaining applicable billing protections, who to contact if these protections are violated, and that patient consent is required to waive billing protections.
Finally, the NSA ensures that uninsured individuals or those choosing to self-pay can receive a good faith estimate of the cost of their care upfront. This estimate must be provided in clear and understandable language, and patients must provide consent to waive their billing protections.
In conclusion, the No Surprises Act provides several federal protections for consumers against surprise medical bills from out-of-network providers. These protections include limiting out-of-pocket costs, prohibiting balance billing for certain services, establishing dispute resolution processes, requiring providers to disclose billing protections, and ensuring uninsured or self-pay individuals receive cost estimates upfront.
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CMS requirements for ADI suppliers
CMS has outlined various requirements for ADI suppliers, which are detailed in the eCFR :: 42 CFR 414.68 -- Imaging accreditation. Firstly, Section 1834(e) of the Act requires the Secretary to designate and approve independent accreditation organizations for accrediting suppliers that provide advanced diagnostic imaging services. These ADI suppliers must be accredited by a CMS-designated accreditation organization.
The accreditation organization must demonstrate its knowledge and experience in advanced diagnostic imaging. They must provide information on their proposed fees for accreditation for each modality, including any plans to reduce costs for small and rural suppliers. The organization must also outline specific documentation requirements and attestations requested by CMS.
A detailed description of the survey process is also required, including the ability to conduct timely reviews of accreditation applications and a description of audit procedures to ensure suppliers maintain compliance. The size and composition of survey teams for each category of advanced medical imaging service supplier accredited must also be outlined.
The organization must also have procedures in place for responding to and investigating complaints against accredited facilities, as well as policies for withholding or removing accreditation status for non-compliance. Additionally, the organization must provide a list of all currently accredited suppliers, the type and category of accreditation held, and the expiration date of each supplier's accreditation.
Furthermore, the Protecting Access to Medicare Act (PAMA) enacted on April 1, 2014, amended Section 1834 of the Social Security Act. This amendment requires that, effective January 1, 2016, ADI suppliers and hospital outpatient radiology departments providing CT services to Medicare beneficiaries must use CT equipment that meets the National Electrical Manufacturers Association (NEMA) Standard XR-29-2013.
In terms of the impact of ownership changes on accreditation status, if a new owner of an ADI facility is not required to submit a new CMS-855(b) enrollment application, the existing accreditation may remain in effect. However, the accrediting organization must provide written permission for the transfer of the remaining term of accreditation to the new owner within three months. If the new owner changes the legal business information, they are required to submit a new CMS-855(b) enrollment application.
CMS also provides educational resources for ADI suppliers, such as the Medicare Learning Network (MLN) and its publications, which offer guidance on Medicare coverage of imaging services.
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Basic standards for hospitals
Standards for hospitals can be developed and used in public regulatory processes, such as licensure for health care organizations, or through private voluntary processes, such as organizational accreditation. Licensure and accreditation focus on reviewing core processes such as credentialing, quality improvement, and risk management. However, they often lack a specific focus on patient safety issues.
In the United States, Medicare and Fortune 500 companies are examples of large purchasers that can impose requirements on hospitals. For instance, the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) requires suppliers of advanced diagnostic imaging (ADI) services to be accredited by a designated organization to receive Medicare reimbursement.
To ensure quality patient care, hospitals should emphasize medical audits and explicit criteria and formal procedures over informal and subjective review processes. Additionally, hospitals should periodically revise their standards based on expert consensus about best practices. This includes addressing any quality problems or indicators identified by survey agencies or Professional Standards Review Organizations (PSROs).
Furthermore, basic standards for hospitals should include expectations for the competence of healthcare practitioners. This includes not only basic and specialized knowledge and skills but also interpersonal skills and the capacity to admit errors. By meeting these standards, hospitals can provide safe and effective care to their patients.
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Frequently asked questions
No, insurance companies do not mandate accreditation for hospitals. However, accreditation is considered a symbol of a hospital's commitment to high-quality, safe care and can provide a competitive advantage in attracting patients. Many payers require accreditation or accept it as a fulfillment of their contractual requirements.
Accreditation is one of the paths hospitals can take to be declared in compliance with the Medicare Conditions of Participation (CoPs). Compliance with CoPs is a prerequisite for payment from Medicare and Medicaid programs, which constitute nearly 60% of hospital costs.
The hospital must undergo a voluntary accreditation process through one of the four recognized accrediting organizations: The Joint Commission, Healthcare Facilities Accreditation Program (HFAP), Det Norske Veritas (DNV), or Center for Improvement in Healthcare Quality (CIHQ).
