decisionhealth Newsletters, Coder Pink Sheets - 2005 Issue 3 (March)
Don't let payers tell you individual credentialing is NCQA standard
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Article Overview
This article discusses payer claims about NCQA credentialing requirements and how those claims affect anesthesia practices and other facility-based specialties. It summarizes commentary from specialty representatives, references payer adoption of a streamlined credentialing approach, and includes an excerpt from NCQA credentialing policy within the MCO Standards and Guidelines. The piece is most relevant to anesthesia billing, provider enrollment, managed care contracting, and organizations trying to understand credentialing expectations.
Why This Topic Matters
Credentialing delays can affect when practitioners can bill and when practices can begin receiving payment. Understanding the scope of NCQA guidance helps practices evaluate payer statements and prepare for contracting and enrollment discussions.
Article Sections
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Payer claims and specialty response
Discusses allegations that payers are citing NCQA standards for individual credentialing and summarizes responses from anesthesia society representatives. It also touches on how the issue is being communicated to practices and plans.
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Payer adoption and operational impact
Describes examples of payer use of a faster credentialing approach and the practical effect on provider onboarding and billing. It also notes reported processing times and administrative workload for new physician credentialing.
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NCQA credentialing policy excerpt
Presents an excerpt from NCQA credentialing policy within the 2004/2005 MCO Standards and Guidelines. The excerpt identifies a category of practitioners that is outside NCQA review.
What You Will Learn
- How NCQA credentialing standards are being discussed in payer negotiations
- Why facility-based specialties may be affected by credentialing policies
- What operational issues can arise when practitioner credentialing is delayed
- How NCQA policy language is being referenced in payer-provider discussions
Who Should Read This
- Anesthesia practices
- Medical billing and coding professionals
- Provider enrollment and credentialing staff
- Practice managers
- Managed care contracting teams
- Healthcare compliance staff
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