Senate Study Committee on
Medicaid Managed Care
Organization Credentialing
Amerigroup Community Care of Georgia
Wednesday August 27, 2014
Mel Lindsey, Senior Director Government Relations
Aaron Lambert, Director Medicaid Field Operations
Amy Martinez, Director Credentialing
Amerigroup Community Care of Georgia
Overview
Member and Provider Profile
•
• Membership: 353,941
•
•
Contract with the Department of
Community Health since July 2006
We are a community-focused managed
care company with an emphasis on the
public sector health care market. We
coordinate the members’ physical and
behavioral health care offering a
continuum of education, access, care and
outcomes resulting in lower cost,
improved quality and better health status
for Georgians
Service Area: 6 Medicaid Regions
o
o
o
o
1
o TANF & CHIP: 327,470
o P4HB: 3,486
o Georgia Families 360: 22,985
• Provider Profile: 23,871
o
o
o
o
1
2
2
PCPs: 3,671
Specialists: 17,050
Hospitals: 143
Ancillaries: 1,840
As of August 2014
As of July 2014
Atlanta – June 2006
East/North – September 2006
Southeast – October 2006
Central & Southwest – February 2012
MEDICAID CARE MANAGEMENT ORGANIZATIONS
CREDENTIALING STUDY COMMITTEE
2
Credentialing Overview
Why we credential
Contract Requirements
•
•
•
Amerigroup is committed to operating an
effective, high-quality credentialing
program
The credentialing process allows us to:
o Ensure our members are receiving
services from fully licensed and
accredited providers
o Ensure our network of providers are
held to a high quality standard
o Detect, avoid, and prevent fraud,
waste, and abuse in our healthcare
system
MEDICAID CARE MANAGEMENT ORGANIZATIONS
CREDENTIALING STUDY COMMITTEE
Adherence to National Standards
o
o
o
•
•
•
•
National Committee Quality Assurance
(NCQA)
Joint Commission on Accreditation
Healthcare Organization (JCAHO)
American Accreditation Healthcare
Commission/URAC
Providers are credentialed in accordance
with State law and Federal regulations
Providers have a valid Georgia Medicaid ID
Allowed 120 days to complete the process
Amerigroup’s credentialing process is
routinely audited by external parties for
compliance to State and Federal
guidelines
3
Amerigroup Credentialing Process
Provider Requirements
Application Check-list:
•







•
•
•
Only accept applications for credentialing
of new providers through the Council for
Affordable Quality Healthcare (CAQH)
Must have an active Georgia Medicaid ID
Each prospective provider, ancillary, or
hospital will complete the joint Medicaid
and Care Management Organization
(CMO) credentialing application
Centralized credentialing application is not
used for:
o
o
o
Providers who currently have an active GA
Medicaid ID
Adding new service locations
Re-credentialing
MEDICAID CARE MANAGEMENT ORGANIZATIONS
CREDENTIALING STUDY COMMITTEE
Curriculum vitae
Liability insurance
Malpractice history
Participating agreement
IPA/PPO/PHO provider acknowledgement
Practitioner attestation
Physician/practitioner credentialing
application and release form
 Physician board certification
 Disclosure of ownership and control
interest statement
4
Amerigroup Credentialing Process
(1) Credentialing
Application Management
(2) Primary Source
Verification (PSV)
(3) Medical Director
Review
• Review all provider credentialing
applications and checks for
completeness
• Responsible for assisting providers
in the application process- answer
questions, respond to inquiries
• Assists provider in obtaining the
CAQH ID number
• Solicits missing, expired or
incorrect documentation that has
been submitted for credentialing
by the Health Plans. Outreach is
made directly to the practitioner
or provider (3 attempts).
• Submits all applications to primary
source verification
• Verification of board certification
• Verification of education and
training
• Verification of work history
• Verification of hospital admitting
privileges
• Verification of state license
information
• Verification of DEA number
• Verification of malpractice
insurance
• Verification of past sanctions
• Verification of responses provided
by the providers credentialing
application
• Verification of the credentialing
applications after PSV review
• Review and makes
recommendation on the “unclean”
file
• Reviews for quality of care issues
identified in the credentialing
application
• Every credentialing application is
reviewed by our Medical Director
• Lead for the Credentialing
Committee
MEDICAID CARE MANAGEMENT ORGANIZATIONS
CREDENTIALING STUDY COMMITTEE
5
Amerigroup Credentialing Process
Other process considerations
•
•
•
•
Each provider has the right to inquire
about the status of his or her application
Each provider has the right to review
information obtained from primary
verification sources during the
credentialing process
Amerigroup allows for delegated
credentialing – assigned credentialing
responsibility to another group or entity
The credentialing process involves
community based providers to participate
in our Credentialing Committee and
Medical Advisory Committee
MEDICAID CARE MANAGEMENT ORGANIZATIONS
CREDENTIALING STUDY COMMITTEE
We credential the following
provider types:











Medical doctors
Doctors of osteopathy, podiatric medicine and
chiropractic
Physician assistants
Optometrists
Nurse practitioners
Certified nurse midwives
Licensed professional counselors/social workers
Psychologists
Physical/occupational therapists
Speech/language therapists
Hospitals and allied services (ancillary) providers
6
Credentialing by the Numbers
% of Time Allocated to Each Credentialing Task (YTD Avg.)
3%
(1) Credentialing Application Management
34%
(2) Primary Source Verification (PSV)
63%
(3) MD Review
2014 % of Time Allocated to Credentialing Task
(1) Credentialing Application Management
(2) Primary Source Verification (PSV)
(3) MD Review
MEDICAID CARE MANAGEMENT ORGANIZATIONS
CREDENTIALING STUDY COMMITTEE
January
25%
69%
5%
February
39%
58%
3%
March
33%
64%
3%
April
32%
65%
3%
May
35%
63%
2%
June
37%
58%
5%
YTD Avg.
34%
63%
3%
7
Credentialing by the Numbers
2014 Credentialing Application Volume
300
# of applications
250
200
150
100
50
0
January
Initial Reciepts
February
March
Practitioner Initial Cred Production
2014 Credentialing Application Volume
Initial Receipts
Practitioner Initial Cred Production
Facility Initial Cred Production
Practitioner Recred Production
Facility Recred Production
MEDICAID CARE MANAGEMENT ORGANIZATIONS
CREDENTIALING STUDY COMMITTEE
April
May
Facility Initial Cred Production
January February
157
212
129
140
22
12
78
243
4
4
March
143
125
11
236
2
April
155
119
9
249
2
June
Practitioner Recred Production
May
179
104
25
180
2
June
196
69
14
182
3
YTD
1042
686
93
1168
17
8
Q&A
Contact Information:
Mel Lindsey: Melvin.Lindsey@amerigroup .com
Aaron Lambert: [email protected]
Amy Martinez: [email protected]