Medicaid credentialing

Originally written by Ho Sun on December 16, 2010: Most of you already know, but Medi-Cal is Medicaid/Public Aid for California by the way.

After some debate, I eventually decided to enroll in Medi-Cal.  As of now, I’m going to take any patient I can.  However, if my Medi-Cal patients eventually overwhelm my practice to the point that I’m losing my Medicare and private insurance patients, I’ll either choose to limit the number of Medi-Cal slots per day, or I’ll stop seeing Medi-Cal patients completely. I guess this is what makes being your own boss so great.

Ideally, I would like to keep a certain percentage of Medi-Cal patients in my practice.  Based on my experience in residency, I found that most of my complicated pathology patients tended to be on public aid.  I don’t want to eventually become that ophthalmologist who treats only dry eyes and cataracts.  I still want to keep my comprehensive clinical skills sharp by having a good mix of pathology in my practice.  Of course,  I don’t want to run a purely NVI/NVG or bad neurotrophic ulcer clinic, but I would still like to encounter disasters every now and then on a fairly regular basis.  I don’t know how realistic or practical this will be, but that’s how I feel right now.

Having said all that, I didn’t know that the obtaining a Medi-Cal number would be more cumbersome than Medicare or private insurance.  As of now, I can’t apply because Medi-Cal requires you to submit a local business license.  I can’t apply for a business license yet because my office is still under renovation, and the fire department will need to inspect the premises before granting a license.  The license will also take 6 to 8 weeks to receive approval.  So, the earliest I can even apply for Medi-Cal will be in February!

Another available option was to join the Santa Clara County Family Health Plan, which is a Medi-Cal based HMO.  I called them to request an application, and it turns out that their network is currently closed because the company is undergoing a transition in management.  Once again, the earliest that these guys will open up their network again will be in February.

So, by no choice of my own, I will not be accepting Medi-Cal.  Given that Medi-Cal pays about a quarter to a third of what Medicare or private insurances pay, it’s interesting how Medi-Cal has been the most difficult plan to join for me.  I guess I’ll apply in February.

Howie’s addendum: the take home point is that Medicaid credentialing varies by state. There is also one important distinction- between straight Medicaid (run by the state, Medi-cal) or a a managed Medicaid plan (private HMO plan). Just because you’re credentialed with one doesn’t mean you’re credentialed with the other! The plans frequently have different reimbursement rates so you can decide which ones to accept (or not). Even if you opted out or closed your panel to new straight Medi-cal patients, you still might see managed care Medicaid patients.

See this post for more details about whether it is worth taking Medicaid.

In Arizona, there is no straight Medicaid. There are five commercial plans: Mercy care, UHC community plan, Health Net AHCCCS, Health Choice and Care 1st. If you live in Arizona, here is the link for credentialing these plans.

Care 1st was the only plan that took me without hassle. Health Choice told me their panel was full, but when I pointed out that I had been credentialed before and asked to speak with the provider rep, they let me into their network. Health Net and Mercy care denied me when I applied as a individual, but I got in network for Health Net through my IPA about four months into practice and through my hospital I got into network for Mercy Care a year and a half after I opened.

The UHC community plan denied me many times stating their network was closed, but I am told that through one of the ACOs that I am affiliated with I’ll get into network this fall.

A lot of docs are fearful that if they are out of network for a certain Medicaid plan, they will lose referrals and their practice won’t grow. I know that I stressed out about not getting on these plans, but everything worked out fine for me obviously.

Or they feel pressured to take any type of plan no matter how low the reimbursements are, even half of Medicare, for fear of losing patients. Especially when they aren’t busy at the beginning. As Ho Sun likes to say, it’s much more difficult to undo something that you never wanted in the first place.

Although initially most ophthalmologists do go in network for most plans, which can be negotiated or dropped later. Keep your sights focused on the long term goal and you’ll be just fine.

2 thoughts on “Medicaid credentialing

  1. In Georgia, you are required to credential through GA Medicaid (using their online portal) and select “CMO Credentialing” to be added to Amerigroup, Peachstate, and WellCare. All recredentialing is done through the portal as well. HOWEVER you must follow up with the CMOs to ensure they have added you. Sometimes they still require additional paperwork. When you select CMO credentialing through the portal, it will automatically add more sections to the web application that are not normally necessary for straight Medicaid. Remember to get all the way through attestation and add all of the required documents.

    –A former credentialing manager/wife of a physician

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    • Thanks for your comments. You’re right every state is different and a google search or speaking with a office manager (or the credentialing expert at your ASC or hospital) can usually point you in the right direction, no need to pay someone to point out the obvious.

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