A new national credentialing process created for chiropractors cuts the massive duplication of paperwork for DCs and MCOs.
Recently, the American Chiropractic Association (ACA) created Quality Verification Systems (QVS), a program intended to streamline the MCO credentialing process for the Doctors of Chiropractic. QVS will make it easier for DCs to become participating providers in MCOs by eliminating a good deal of the duplication and expense, for both the doctor and MCO, entailed in processing applications and credentialing DCs. It was the changing health care environment that created a need for the QVS system; the factors that culminated in its development are described in the following paragraphs.
The shift from indemnity health insurance products to managed care shattered chiropractors’ sense of assurance that the health care claims they filed on behalf of their patients would be paid. At the same time, the advent of self-insurance began to chip away at the gains the profession had previously enjoyed in the area of insurance equality. Self-insured health plans are exempt from the mandates dictated by state law, through the federal ERISA exemption. The impact of managed care and self-insurers first hit the profession in the late 1980’s, and their effects are just as potent today.
The combined impact of these structural changes on the third party pay system has been a steady downward pressure on the mean incomes of practicing chiropractors. In addition, the administrative burdens of managed care have detracted from net incomes. DCs have had to add staff and shift critical resources to the non-clinical aspects of practicing in a managed care environment. The correct handling of all the “paperwork” for such requirements as treatment authorization, claims justification, and securing referrals on behalf of patients has substantially cut into net income. As well, the arduous process of applying to become a provider in a health plan and collecting all the requisite credentialing information for health plans has added to the expenses of working in the new third party pay environment.
For the first time, net incomes began to decline in 1988; the decrease continued in 1989 and persisted through 1990. Although many factors contributed to the decline, clearly the administrative burden of managed care was a key factor.
As the managed care market has matured, health plans have developed contracting mechanisms for provider participation. For DCs to maintain and grow their patient base, they need to contract with numerous health plans in their area. Typically, a lengthy application must be completed for health plan participation; also required are copies of licenses, malpractice insurance certificates, and a curriculum vitae, with attachments that explain any gaps in work history. Most important for QVS is the redundancy of all this: Each health plan has an application process that essentially duplicates the others.
The MCOs have begun to use credentialing as one measure of plan quality. They do so because they, in turn, seek accreditation by accrediting agencies, such as the National Committee for Quality Assurance (NCQA). Employer groups, as purchasers of health plans, look for plans with appropriate accreditation as one measure of value of the health products they buy.
NCQA has an accreditation process that requires health plans to credential providers, including chiropractors. NCQA has established monitoring standards for credentialing Doctors of Chiropractic. (For a list of the NCQA standards, turn to page 38). For each of the NCQA monitoring standards, health plans apply criteria that determine whether a provider meets credentialing requirements. These criteria are developed by the health plans’ credentialing committees; the committees make the determination as to which providers are credentialed and which are rejected. NCQA standards require health plans to perform primary source verification of the various credentialing elements. For example, a health plan must contact the malpractice insurance carrier directly to “primary source verify” a doctor’s history of malpractice claims.
QVS IS CREATED
In 1995, the ACA conducted a survey of the chiropractic profession. At that time the majority of DCs noted the administrative burdens described above involved in contracting and credentialing. Seventy-eight percent of the respondents to the survey asked for a national credentialing process; one that MCOs could access for Doctors of Chiropractic. The ACA took the important step of responding to this need by including within ACA’s long range plan a specific goal calling for the creation of a National Chiropractic Credentials Verification System. In late 1997, ACA created the Quality Verification Systems (QVS), to help DCs qualify for participation in MCOs; further, to identify key quality measures in their practice.
The first to be launched by ACA is within QVS’ quality measures component; specifically, a credentials verification system. Other components will be added in the future. The credentials verification system is a credentialing database that can be easily accessed by health plans to credential DCs. This database consists of the credentials files of individual DCs who participate in QVS.
Participants in QVS complete a standard application. Next QVS uses the standard physicians application created by the American Association of Health Plans (AAHP). This application was chosen because it is the only standard application in the managed care industry. A critical element of QVS’s mission is to streamline the application process.
Although many health plans use their own application forms, most observers believe that the standard application will be used by increasing numbers of health plans in the future. QVS data entry personnel transfer information from the application to the database, and thereby create an electronic file for the information. QVS staff then perform primary source verification of the data elements required by NCQA. That “file,” with permission of the “owner” (doctor), can then be accessed by health plans seeking to credential Doctors of Chiropractic.
The full collection of “files” (database) is marketed to health plans around the country as a primary-source-verified database of Doctors of Chiropractic who are interested in participating in managed care plans. MCOs seeking to credential their network, or MCOs building chiropractic networks can easily access this database.
The clear advantage for QVS-participating doctors is the ease with which the file can be used by health plans and the fact that they are included within a broad-based marketing effort that gives them significant additional exposure to health plans across the nation.
ACA is collaborating with Credential Assurance Group of America, Inc. (CAGA) to administer QVS. CAGA is a national firm that is certified by the National Committee for Quality Assurance (NCQA) as a credentials verification organization (CVO). Operating since 1992, CAGA pioneered the field of centralized credentials verification when it successfully implemented a HCFA-funded demonstration of CVO operations in Wisconsin. With its primary focus on health care practitioners, CAGA has underscored the importance of addressing the increasing administrative burden on practitioners arising from managed care contracting. More recently, CAGA has made even further strides toward improving the position of health practitioners by merging with Digital Medical Registrar, Inc. (DMR) of San Diego to introduce the most modern information technology and process information faster and more cost effectively. It is CAGA that actually performs all the data collection and verification. Because confidentiality is a necessity, the QVS participant’s file is never actually seen by the anyone in the ACA.
Currently, CAGA is transferring the QVS database to an on-line service. The on-line service will make the QVS database (participating doctors) even more valuable to potential MCO clients: They will be able to subscribe to the on-line database and “check” (with the permission of the doctor) the credentials of applicants quickly and at greatly reduced costs. The on-line database will also allow participating doctors to have their credentialing information printed directly on any MCO application form that is recognized by the on-line service, thus eliminating duplication of effort involved in completing MCO applications.
Already, QVS has become an extremely popular ACA program. Within its first few months, several thousand ACA members requested QVS application materials. In the near future, QVS will be made available to non-ACA members as well, but ACA members will always enjoy significantly lower participation fees.