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Rep. Matt Baker Introduces Credentialing Reform Legislation


By Scot Chadwick

​Citing a need to improve access to care and eliminate unnecessary costs in the health care system, Rep. Matt Baker (R-Tioga County) has introduced HB 1663, prompt credentialing legislation that has PAMED’s strong support.

Rep. Baker’s bill specifically addresses the problem of unwarranted delays by health insurers in credentialing applicants for inclusion in their networks. Hospitals and physician practices routinely face the situation where a newly hired health care professional who is fully licensed and qualified to provide care is not reimbursed by insurers for months while the insurers work their way through an unnecessarily long and cumbersome credentialing process.

This costs hospitals and physician practices money, drives up the cost of health care, and limits access to care by keeping fully licensed and qualified providers on the sidelines until they are credentialed by insurers.

The ability to transmit data and process applications electronically long ago eliminated any justification for a lengthy insurer credentialing process, and Rep. Baker’s legislation will establish a standardized process and timeline for insurer action on credentialing applications. Key elements of HB 1663 include the following:

Uniform application form

Beginning on Jan. 1, 2016, all health insurers licensed to do business in Pennsylvania would be required to accept the Council for Affordable Quality Healthcare (CAQH) credentialing application when submitted by a health care practitioner for participation in the insurer’s provider panel.

Provisional credentialing

If a health insurer fails to issue a credentialing determination within 30 days after receiving the completed CAQH credentialing application, the health care practitioner shall be deemed provisionally credentialed. A health care practitioner would be eligible for provisional credentialing if (1) the health care practitioner has applied to participate in the insurer’s provider panel for the first time, or (2) the health care practitioner is a member of a provider group that is a participating provider.

Coverage and reimbursement during provisional credentialing

A health insurer shall provide coverage and reimbursement for services rendered by an applicant granted provisional status under the same terms as are applicable to participating physicians in the applicant’s provider group.

The bill also contains enrollee protections during an applicant’s provisional credentialing status, and administrative penalties on health insurers for failure to comply with the bill’s provisions. We believe these steps will go a long way toward eliminating unwarranted delays in processing credentialing applications, resulting in both cost savings and improved access to care, without in any way sacrificing patient safety.

PAMED thanks Rep. Baker for his leadership on this important issue, and urges physicians to join in this effort by contacting their local House member and asking them to support HB 1663.

We’ll be sure to keep you up to date on our efforts to enact the bill. In the meantime, you can reach our advocacy department with comments or questions at (717) 558-7823. Or, if you’d like to share your views more broadly, feel free to leave a comment below.

Related Content

PAMED is also working closely with the Department of Human Services to ensure more timely credentialing of physicians in the state's Medicaid program. After discussions led by PAMED, DHS announced that, beginning in 2016, it will impose additional requirements on its Physical Health Managed Care Organizations (PH-MCOs) related to credentialing timeframes. Among them, PH-MCOs will be required to begin their credentialing process upon receipt of a provider’s application. If the application contains all of the required information, they must complete the credentialing process within 60 days. Learn More

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