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

September 21, 2021 in Resources

Insurance companies offering in-home care and support services face a major challenge: The demand, specifically from Medicare, for credentialed service providers for aging-in-place Americans is far greater than the supply. 

Even with this reality, insurers don’t have the option to simply cut corners in the credentialing process. Medicare Advantage (MA) service providers are expected to help seniors with tasks in and around their own homes, resulting in an increased need for standards and oversight.  

Let’s investigate what this means for the future of MA plans, service providers, and members.

The State of Medicare Advantage

By 2040, 80 million adults in the United States will be over the age of 65. 

As Americans age, nearly 9 out of 10 prefer to do so at home or with loved ones. The popularity of aging in place means that more Americans are looking for in-home services that go beyond the scope of the original supplemental Medicare Advantage benefits like dental, vision, and hearing. 

Today, older adults are also looking for quality, reliable providers to fulfill services like grocery and meal delivery, lawn care, home maintenance, and beyond. These additional supplemental benefits—which became part of MA in 2019—place a lot of pressure on the MA plans themselves.

A complete solution that provides quality care and support services through trusted providers will greatly reduce the time older adults spend without the care they need, thereby improving outcomes for insurers and insureds. But more on that later…

The Role of Credentialing in Medicare Advantage Services

Credentialing encompasses the thorough review and qualification processes that providers must go through to be added to an insurer’s preferred list or network. It has long been a part of federal requirements for Medicare providers and suppliers. 

By establishing networks of credentialed providers, MA plans can offer a range of services while safeguarding the well-being of beneficiaries. Through the creation of credentialed networks, there is also a shift toward value-based care models which means providers are paid based on the quality of service provided, rather than visit volume. 

This is critical in achieving The Triple Aim. The Triple Aim, “a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance,” is used to improve the quality of care and member experience while reducing the costs of care. 

But building credentialed networks isn’t an easy task.

The Complexity of Credentialing 

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

This is especially true with new, non-traditional supplemental benefit service providers. Insurers do not have the experience of identifying, selecting, contracting and credentialing these provider types. Furthermore, the providers themselves often do not have a deep understanding of the complex rules and regulations of MA. 

If an insurer takes on the building of a network, they must first understand 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 insurer.

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 insurers try to streamline this process, they may opt to hire just one provider to resolve the growing administrative problems that come with a credentialed network. What this option does instead is creates 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 to thousands of providers to offer a complete solution for their beneficiaries.

Still, the benefits of offering credentialed service providers far outweigh the costs. MA members love the supplemental benefits that support them while aging in place. That means the most successful MA plans are those who can provide the most credentialed service providers, at the fastest fulfillment rate, for the best value. 

The incentives have resulted in competition among MA plans. It’s a race to deliver the highest value to members. 

The Competitive Landscape of Medicare Advantage 

Medicare Advantage quickly broke away from the pack by expanding the range of services offered in 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. 

For MA plans to stand out from the competition, they must differentiate themselves through improved offerings, higher-quality services, and a greater sense of security.

While MA plans 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, Long-term Care Insurance (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 the quality of care, and reduce costs.

Conclusion

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 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 continue to 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 The Helper Bees 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. 

That’s where The Helper Bees comes in.

The Helper Bees homeAlign platform makes it easy for MA plans to deliver timely, credentialed services to aging-in-place Medicare Advantage members. The platform monitors the performance of the network service providers based on member/client grievances, timely clinical escalations, timely claims/billing submissions, no-show and cancellation rates, and documented concerns. 

In other words: As issues arise, The Helper Bees handles them. The Helper Bees 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 provider fails to meet the expectations of the CAP, termination may be a viable course of action.

The Helper Bees helps MA plans create and monitor a network management process that will help to ensure that only the highest-performing providers will remain in the aging-in-place network, allowing insurers 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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