The Vital Role Credentialing Plays in Providing Quality Care to Aging Americans

September 21, 2021 in Resources

The Cost, Quality, and Fulfillment Challenges Related to Aging-In-Place Services Provided by Medicare Advantage and Long-term Care Insurance Carriers 


The Shift Toward The Home

According to recent population data, the U.S. is on the steepest slope of an unprecedented demographic shift. By 2040, there will be 80 million adults aged 65+. The shift, coupled with the fact that 86% of Americans want to age at home or with loved ones, means the demand for in-home support services will continue to rise, reaching new heights over the next 20 years. This places disproportionate pressure on the payers of long-term care in America, specifically Medicare Advantage (MA) and Long-Term Care Insurance (LTCI). 

The Continuum of Care for Aging In Place

As the concept of aging in place becomes more mainstream – and popular – older adults are looking for in-home services that go beyond the scope of traditional offerings (i.e., dental, vision, hearing, etc.) and quality, reliable providers to fulfill those services. Since aging needs change over time and from individual to individual, the range of services needed to support older adults is dynamic and diverse. 

Those who attempt to self-manage their aging needs often experience frustration when navigating scheduling, coordinating, and invoicing across multiple providers. Routinely carriers utilize provider networks to ease this burden and bridge gaps in care for their insured.

Without a network, finding providers who are qualified with respect to skill, credentials, and safety is often a hurdle that becomes just one more reason for older adults to delay making arrangements. The lag time between need and fulfillment emphasizes the importance of an all-encompassing strategic approach to provider selection, enrollment, and credentialing especially when it comes to aging. A complete solution that provides quality care through trusted providers will greatly reduce the time older adults spend without the care they need, thereby improving outcomes for carriers and insureds.

The Value of Credentialing

Credentialing encompasses the review and qualification processes that providers must go through in order to be added to a preferred list or network. It has long been a part of federal requirements for Medicare providers and suppliers. Medicare’s focus on The Triple Aim to improve quality of care and member experience while reducing the costs of care, serves as a useful guide in credentialing. The goal of credentialed provider networks is to move toward paying providers based on the quality of care they deliver, rather than visit volume.

Credentialing is critical to creating a network of trustworthy and vetted providers. Without a robust and formal credentialing process, members are no better off than if they simply used an online search tool to find the aging-in-place services they need. By relying upon an informal network of non-credentialed providers, payers are unable to scale their service offerings due to fulfillment challenges. The payers also have no control over provider rates or the quality of the services provided.

The Competitive Landscape of Medicare Advantage 

Medicare Advantage (MA) quickly broke away from the pack by expanding the range of services offered into the home in 2019. Since then, the popularity of MA has continued to increase with enrollment numbers climbing and the number of plans increasing to meet that growth. However, in order to rival the competition, many plans are looking for ways to improve offerings, increase value, and differentiate themselves.

While MA carriers have experience with in-home care and medical service providers, they are now grappling with the challenge of how to include non-medical services in their “triple aim” goals. The most successful plans will create strong, agile, and scalable networks of credentialed providers to serve their members. 

Meanwhile, LTCI carriers are just beginning to explore in-home care options as a more cost-effective alternative to facility-based care. LTCI, like MA, will benefit from the development and utilization of credentialed provider networks to facilitate care delivery, improve quality of care, and reduce costs.

The Complexity of Credentialing 

While the outcome of credentialing is attractive to both carriers and insureds, the process is time-consuming and burdensome for carriers, requiring resource dedication for research, coordination, and compliance verification. 

The time and effort involved in monitoring license and service data for thousands of service providers across the U.S. can amount to hundreds of person-hours per carrier. While third-party credentialing is available, it is often limited in scope, not focused on the specific services needed for those aging in place, and not equipped to include supplemental service providers. 

Service providers usually have to submit: 1) a written application, 2) proof of required licenses, 3) verification of information from primary and secondary sources, and 4) confirmation of eligibility for payment. The MA plan must have written policies and procedures to ensure all approved service providers follow these steps in order to conform with Medicare requirements for provider selection and evaluation. 

When payers try to streamline this process themselves, they may opt to hire just one provider to resolve the credentialing problem, but what they do instead is create a fulfillment problem. Plans need the breadth and diversification of a larger network. Based on recent data, most providers are only able to fulfill 10-15% of referrals. This means an MA plan would need to coordinate with hundreds of providers to offer a complete solution for their insureds. 


It’s clear that credentialing is not a simple task and the difficulty of credentialing is compounded by the type of vendor. Historically, Medicare has credentialed medical-related products, which is why there is well-defined regulatory oversight and thus protocols for quality. With the increase in non-medical supplemental benefits by Medicare Advantage plans, the typical credentialing playbook is not one that these plans can follow. 

For instance, the same process to credential a medical provider is not one you can typically use for a non-medical caregiver who is assisting with homemaker tasks. This is the problem that MA plans were faced with in 2019 with the expansion of supplemental benefits to reimburse for in-home care. Luckily, companies like healthAlign were delegated to help create and implement the credentialing process for these benefits. The company was able to tackle the credentialing of non-medical services for a health plan through verification of licensure, insurance, preclusion lists, sanction lists, state-specific verifications, and policies and procedures.

As the number of in-home supplemental benefits has exploded, so too has the need to create a similarly standardized credentialing process for the personal assistance benefit. Health plans are beginning to provide services to promote aging in place. These services include but are not limited to pest control, meal delivery, and home modifications. Once again, healthAlign has begun to create the process by which the company will define what a quality provider is.

healthAlign will monitor the performance of its network service providers based on member/client grievances, timely clinical escalations, timely claims/billing submissions, no-show and cancellation rates, and documented concerns. As issues arise, regardless of the source, they will be addressed immediately with corrective action. healthAlign will give a reasonable amount of time for the provider to rectify the situation with a clearly defined and measurable corrective action plan (CAP). If the subcontractor fails to meet the expectations of the CAP, termination may be a viable course of action.

It is healthAlign’s goal to create and execute a network management process that will help to ensure that only the highest-performing providers will remain in the aging-in-place network, allowing carriers to expand their offerings with peace of mind. This in turn means that the aging experience will continue to improve for those who choose to age independently at home, dramatically changing how and where Americans age.

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