HOUSE BILL REPORT

EHB 1552

This analysis was prepared by non-partisan legislative staff for the use of legislative members in their deliberations. This analysis is not a part of the legislation nor does it constitute a statement of legislative intent.

Background:

Provider credentialing is the process that insurance carriers use to ensure that a health care provider is qualified to provide care and treatment to their members.

The Office of the Insurance Commissioner (OIC) is required to designate a lead organization to develop a uniform electronic process for collecting and transmitting the necessary provider-supplied data to support credentialing, admitting privileges, and other related processes. The OIC selected OneHealthPort as the lead organization, which developed the credentialing database, ProviderSource.

Health care providers are required to submit credentialing applications to ProviderSource and health carriers are required to accept and manage credentialing applications from the database. A health carrier must approve or deny a credentialing application submitted to the carrier no later than 90 days after receiving a complete application from a health care provider.

Beginning June 1, 2020, the average response time for the health carrier to make a determination regarding the approval or denial of a provider's credentialing application may not exceed 60 days. If there is a credentialing delegation arrangement between a facility that employs health care providers and a health carrier, then the single credentialing database is not required to be used and the timelines do not apply.

Summary of Engrossed Bill:

A health carrier may not require a health care provider to submit credentialing information in any format other than the database selected by the Office of the Insurance Commissioner for purposes of collecting and transmitting credentialing information.

The provision requiring the use of the credentialing database does not apply to health care entities that utilize credentialing delegation arrangements with carriers.

If a carrier approves a health care provider's credentialing application, upon completion of the credentialing process, the carrier must reimburse a health care provider for covered services provided to the carrier's enrollee under the following circumstances:

When credentialing a new health care provider through a new provider contract, the carrier must reimburse the health care provider retroactively to the date of contract effectiveness if the credentialing process extends beyond the effective date of the new contract.
When credentialing a provider to be added to an approved and in-use provider contract between the carrier and the health care provider or the entity for whom the health care provider is employed or engaged, the carrier must reimburse the health care provider for services beginning when the health care provider submitted a completed credentialing application to the carrier.

The health carrier must reimburse the health care provider at the contracted rate for the applicable health benefit plan that the health care provider would have been paid at the time the services were provided if the health care provider were fully credentialed by the carrier.

Staff Summary of Public Testimony:

(In support) This simple bill will have a huge impact. Many health care providers' offices run on a shoestring budget and when a new physician is hired, the practice must pay that person's salary. However, the office cannot get reimbursed for care the physician is providing until they are fully credentialed, which puts the practice in a financial bind. All of the financial risk is borne by the providers who are hiring.

Credentialing is a very important process to ensure that providers are fully qualified. However, the process takes a very long time and is administratively burdensome. The process becomes even more time consuming and complicated where carriers require the use of systems outside of ProviderSource. This slow process sidelines providers that could otherwise be taking care of patients. This bill would improve this by requiring reimbursement during the credentialing process and shortening the credentialing timeline. Medicare currently retroactively pays providers; if Medicare can do it, so can all of the other insurance companies. This practical bill will help ensure the viability of small practices.

(Opposed) Credentialing is an important process to ensure that Washingtonians receive quality care. During the process, carriers must check that the providers have the necessary credentials, check disciplinary actions, and check for past crimes. This all takes time. In 2016 the Legislature agreed to pass a bill with reasonable credentialing timelines that were agreed to through a carefully negotiated process. These timelines have only been in place for a year and previously there was no timeline. These should be allowed to stand.

Persons Testifying: (In support) Representative Dolan, prime sponsor; Jeb Shepard, Washington State Medical Association; Patty Seib, Washington Academy of Family Physicians; Lisa Thatcher, Washington State Hospital Association; Eddy Cates; Christie Mcannally, Pioneer Family Practice; and Ken Lee.

(Opposed) Christine Brewer, Association of Washington Healthcare Plans; and Mel Sorenson, America's Health Insurance Plans.