Expedited Provider Credentialing
The legislation requires that Medicaid managed care organizations (MCO) establish and implement an expedited credentialing process that would allow certain applicant providers to provide services to recipients on a provisional basis. The legislation directs the Texas Health and Human Services Commission (HHSC) to establish the types of providers who will be eligible for expedited credentialing. However, to qualify for expedited credentialing the applicant, at minimum, must:
- be a member of an established healthcare provider group that has a current contract in force with an MCO;
- be a Medicaid-enrolled provider;
- agree to comply with the terms of the MCO’s provider contract; and
- submit all information required by the MCO.
A provider will be treated as a provisional provider upon submission of the required information. However, if the provider is not ultimately approved by the MCO, the organization can recover from the provider the difference between payments for in-network benefits and out-of-network benefits. If the MCO determines that the provider made fraudulent representations in the application, the entire amount paid will be recoverable.
Medicaid Managed Care Access-Related Contracting Requirements
The new law also changes the requirements for Medicaid MCO contracts, which now must:
- Provide a comprehensive plan that describes how it will meet the new provider access standards HHSC has been directed to establish under the legislation for preventive care, primary care, specialty care, after hours urgent care, chronic-care, long term services and supports, nursing services, therapy services and any other services identified by HHSC. The access standards must take into account urban and rural access differences and consider the geographic distribution of providers in each applicable service area.
- Continue to comply with the access standards during the term of their agreement and make “substantial efforts” to mitigate any noncompliance.
- Pay liquidated damages for each failure to comply with the access requirements.
- Regularly report to HHSC and the public on the sufficiency of the organization’s provider network with specific information regarding access to primary care, specialty care, long term services and supports, nursing services and therapy services.
The legislation also provides that HHSC must directly monitor the MCO’s compliance with requirements related to (1) the number of providers accepting new patients under the Medicaid managed care program, and (2) the length of time a recipient must wait between scheduling an appointment with a provider and receiving treatment from the provider.
If an MCO that has contracted with HHSC to provide healthcare services to Medicaid managed care recipients fails to comply with the provider access standards and if HHSC determines the MCO has not made substantial efforts to mitigate or remedy the noncompliance, HHSC may (1) elect not to retain or renew the contract with the MCO, or (2) require the MCO to pay liquidated damages for each failure to comply. Additionally, HHSC shall, if the MCO’s noncompliance occurs in a service area for two consecutive quarters, suspend the default enrollment of recipients to the organization in such service area.
Recipient Access to Provider Information
The new law also requires contracted MCOs to maintain and distribute provider directories on their websites, along with a phone number and an e-mail address for enrolled recipients to receive assistance in finding providers and scheduling appointments. The provider directory information must be updated on a monthly basis.
Furthermore, recipient access to support and program information has been broadly expanded as HHSC is now required to use a variety of agencies and non-profit entities to provide such information. The redistribution of information services to local agencies may allow providers additional marketing avenues.