Licensing and Credentialing Nonsense with Assured

TL;DR 

Licensing and credentialing is a process where clinicians need to fill out a lot of separate forms per state and per payer to demonstrate they’re in good standing and can deliver the medical services they say. This involves getting a bunch of certificates, writing up duplicative info, and then following up with the state medical boards and payers. We go through the wacky parts.

Assured is a company that uses software, AI, etc. + licensing/credentialing experts on staff to speed up and monitor the licensing, credentialing and payer enrollment process. 

We talk about the pain points they address but also the issues they might face including companies in-housing this function, anti-bot provisions, and the process just becoming easier itself.

This is a sponsored post.  You can read more about my rules/thoughts on sponsored posts here. If you’re interested in having a sponsored post done, we do four per year. You can inquire here.

Company Name - Assured

The company is named Assured, apparently not pronounced “ass you red”. They handle the licensing, credentialing, and enrollment process for companies and clinicians.

The company name is inspired by Usher, who just like licensing is somehow frozen and unaging since the 2000s. 

Honestly, the process itself is enough of a joke that we can just go straight into it.

What is Provider Licensing and Credentialing?

When any clinician wants to be able to bill insurance, there’s usually a 20 step process. 

• Licensing
• Contracting and enrollment
• Credentialing
• And do that again like 16 times

Licensing is independent of the insurance process, but becomes used later. In every state, a clinician has to apply to the state licensing board and show them that they graduated from school, passed the necessary exams, etc. Here’s an example from Florida, you get all the fun of paying the application fees AND dealing with a website that uses “poo brown” in its color scheme.

Double the fun, you have to do this for every state you want to practice in! And many states have their own processes for things like fingerprints or vendors they use for background checks. In some states if you’re a nurse practitioner, you might need to get your registered nurse license, get your nurse practitioner license, and then a prescriptive authority certificate in order to prescribe. And for many states it has to be done IN SEQUENCE, so it can take many months.

After licensing, the following steps can sometimes be sequential or happen in parallel depending on the payer's level of competency.

During the contracting process, an insurance company looks at the current providers they’re in-network in and decide whether they want to add you to the network. This can be some combination of if they need more doctors of a certain kind in-network, whether the provider delivers good care, employer/consumer demand for a given provider, etc. If the insurance decides they want you in-network, they’ll give you a fee schedule (aka. what they’ll reimburse you for different services). Psst we go through this in the payer contracting course.

During the credentialing process, the insurance company wants to make sure that the clinician is legitimately able to offer these services. This means that health insurers (and government programs like Medicare/Medicaid) will ask these doctors to submit a ton of materials to them to prove they’re legit. 

While there’s some variance in terms of what they’ll verify, most of them will ask for the following:

• General information like name, national provider identifier, etc.
• Work history - apparently gaps longer than 3-6 months get interrogated
• Board certifications
• Professional training (e.g. med school, residency, etc.) and copy of your diploma
• Where you have hospital privileges
• Your malpractice insurance and any past malpractice claims
• Any sanctions against you by the government or regulatory bodies or the National Provider Data Bank
• State medical license or the equivalent for your clinical level
• DEA (drug enforcement agency) certificate to prescribe controlled substances
• Controlled Dangerous Substances (CDS) certificate

In many cases the insurer will require the primary source that proves it. Remember the process for getting your college transcript? Imagine that but like 5-10 different places and half of them still require postage. 

On top of that, you might see some variation by health plan or state that could require things like a copy of your social security card, peer reference, etc. Once they get these documents, there’s a credentialing committee that meets regularly and goes through these applications to approve them. I can’t imagine anyone on a committee like that having light in their eyes.

Many payers will require providers to re-credential every ~3 years and re-attest a few times a year that they’re in good standing. Here are some examples of credentialing forms.

If all goes well, then the clinician is enrolled into the health plan. This means that they get set up in their directory, they’re enrolled in some method of receiving payment to their bank, spit on as a dominance thing, etc.

While some individual clinicians will do this whole process with payers themselves (e.g. if they’re a solo practitioner), most will do this underneath an umbrella organization. For example, you could be working for a hospital which has its own rates with insurance and does the contracting process themselves. But if you work in the hospital, you’re required to get credentialed at the individual level before you start working.

Sometimes, insurance companies will actually push the onus of checking these credentials to third party entities that hire the clinicians. This is called “delegated credentialing”, where the payer gives credentialing authority to another party like the hospital itself. Meeting the requirements to become a delegated credentialing entity isn’t easy; there are hundreds of pages of rules to comply with from places like NCQA, you’ll get audited periodically by the payer, and you usually have to perform the credentialing process on clinicians much more frequently.

In many cases, hospitals can be delegated to handle the credentialing. So the hospital will handle both the contracting AND credentialing for the clinicians. This is also common for billing groups if a bunch of physicians bill under them.

What’s the Pain Point?

I mean this whole thing sounds like a mess, and it is. There’s so many portals to navigate through, the responsiveness of every entity involved is basically zero, and you have to repeatedly ask for updates to get things through. There are PDFs that float around, wet-ink signatures that are “required” when it’s not a legal requirement, and standard forms that ask outdated questions like “what’s your home phone number?”. 

I understand the need to make sure everyone’s in good standing, but so much of this is duplicative paper pushing.

Some simple and annoying things:

• This process can take months, the average time for credentialing alone is 90 -180 days depending on the state/payer. This can take even longer in some instances where a Managed Medicaid payer for example might not start the process until you’ve enrolled with the state Medicaid directly, doubling the timelines. And you’re considered out-of-network until the process is complete. If you’re joining a new institution, you frequently need to get credentialed before you can work there, so you have frontline staff driving for Lyft while they wait.

• Most of the medical boards ask for the same things for licensing. Most of the credentialing entities ask for the same things as each other. Why not just coordinate and have one standard for all of it? You do see movement towards this. There’s a movement for states to adopt an interstate license, but implementation is spotty (though getting much better). The Council for Affordable Quality Healthcare (CAQH) has a kind of “common app” for credentialing where providers can go into one portal to update their information, and payers can just check that database. However, not every payer uses it, and even the ones that do sometimes ask extra credentialing questions on top.
• Everything costs money. Each state’s board of medicine charges hundreds to thousands of dollars per clinician for licensing (e.g. New York is $700+). Even just to send the primary source to the credentialing department can cost money. Sure, lots of these certificates are $15-30 but you have to do it for each certificate, each credentialing process, and for each clinician every few years. It adds up; is it worth it?

• Somehow this process combines the worst of software and human review. One typo and your application gets flagged and put to the back of the line. If a reviewer is confused about something because they’ve never heard of it personally they’ll flag and push you to the back of the line. 
• It makes it harder for clinicians to switch employers. Going through the credentialing process adds a few months between an offer being signed and starting, which is annoying and might force them to go without a paycheck in between.
• Despite all of this process, it still doesn’t prevent some very egregious people that seem to slip through the cracks. Dr. Death (Christoper Duntsch) is a great example of this, who managed to evade red flags because every institution he worked at or graduated from omitted his mistakes. Here’s an example of how this played out with a drug abusing anesthesiologist, where his practice sued the previous places he was employed for writing glowing reviews that let him pass credentialing.

Anyway I could rant about this for a while, but the main issue for anyone that employs clinicians is that they need to go through this process for each clinician and each health plan regularly and it’s a lot of manual and annoying work.

What Does Assured Do?

Assured helps companies handle the licensing, credentialing, and enrollment in health plans. They use a combination of automations to gather and submit the data + software to track the process + credentialing experts to take this process off your plate. 

Customers onboard their clinicians practice information, W-9s, etc. Clinicians can securely give Assured credentials for logging into the various portals like CAQH and the various certifying boards. Assured then uses automations in the background + screen scraping to pull all the disparate information, primary sources, etc. into one place to create a provider profile.

With the provider data in one place, they use automations to submit data to the various medical boards, payers, etc. They then keep following up with the departments they submit to for updates on where the application is in the process. It’s like the “you up?” text, but to be able to practice medicine. 

As you can imagine, automation doesn’t get all the way there for both the information retrieval or the submission process. Every form is slightly different, so they need to have a credentialing human in the loop to fill in any gaps, make requests of your organization if they need additional information, and more. This can happen when you need wet ink signatures, notarized forms, or need to mail or god forbid fax things.

This product is not really rocket science. Getting a clinician into a payer’s network just requires filling out a million different forms, knowing what to submit, and following up regularly with the providers for additional information and committees in charge of credentialing. For most of their customers, their edge isn’t “we credential faster”, so they outsource this. Software is good at filling out forms, experts are good at making sure it’s being done correctly and filling in the gaps. 

What Is The Business Model And Who Is The End User?

The business model is a base SaaS fee + usage based billing. The end user is usually an operations associate within provider networks that works at a digital health company, health system, or health plan. 

Assured has focused their product for companies with delegated credentialing. These are the companies that represent networks of clinicians where all of them bill under the one umbrella company. They have the authority to run their own credentialing processes and background checks, and Assured will work with these companies to automate those processes.  

Assured will also work with any provider/clinician that has to enroll in multiple states with multiple payers (telemedicine, multi-state expansion, etc.)

Job Openings

You can see all of Assured’s job openings here. A few specific ones below:

• Director of Licensing
• Director of Credentialing

Out-Of-Pocket Take

A few things that I think are interesting about Assured:

Managed services - Licensing/credentialing will most likely always need a human in the loop to verify documents, handle edge cases, etc. So, it makes sense that they offer this as a tech-enabled service to companies. In particular, this is useful because a lot of the software is actually a collection of hacky scripts that need to be updated pretty regularly.

Previous companies in the Robotic Process Automation space have tried to sell the tool to ops teams and have them build automated workflows for everything. This is tough because it puts the onus of learning the software on the company. Plus, automation for everything sounds nice until everything breaks because the button moved on a webpage and you didn’t build a monitoring solution for that.

By taking over the whole process with software + humans, Assured can push more automations and tackle edge cases with their staff without the customers needing to relearn things. For something like credentialing where it’s basically navigating a bunch of janky sites and forms, this arrangement seems to work better than selling automation alone.

The scrapers - This is more of an ideological thing. Assured uses scrapers and automations to get data out of lots of different portals. Do you believe that data repositories should be able to make it difficult for 3rd parties that want to get that data out using bots but for legitimate use cases? 

Financial services went through this fight years ago, with companies like Plaid using user credentials to essentially scrape their way into banking portals. You’re now seeing this in healthcare, with lawsuits like PointClickCare vs. Real Time Medical Systems happening in areas where bots are being used to get data out of repositories to make life easier for the users themselves.

I think scrapers are useful if they’re using it for legitimately more efficient processes that the user themselves want to do faster. Assured does this for credentialing, a process that frankly should already be more efficient. And they use a lot of the new AI tools to get around bot prevention so they can get clinician documents more easily for them from these very separate data repositories. Personally, I think that’s a worthwhile fight.

Provider identity - Assured has big dreams, as they should. As with any company that’s read Lean Startup once, they want to start with one clear pain point and eventually move into other areas. Since they’re already getting all the docs relevant data into one place, they want to use that to potentially get into other areas. For example, creating a new provider dataset for third parties to keep their directories up to date, or even a provider ID that doctors can use to log-in to other third-party apps (like single sign-on, but for docs).

To make that happen you basically have to win the whole market so…it’s a pretty tall order. But I think big ambitions are good!

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As with any company - Assured will have several things to grapple with as it grows.

Is software a differentiator? - An open question is how useful software is in this process. The team has built a lot of automations that can get through the rote data collection, submission, and application monitoring. But that leaves two existential questions:

1. How brittle is the software that enables something like this? If portals start implementing anti-scrapers or the web pages change, a lot of this software can break. What does the implementation/maintenance cost look like for this over time.
2. How much does software matter in the value proposition? You can have the best process to gather the documentation and fill out forms. But many roadblocks are just human issues like “getting a doctor to fill out a peer reference”. The payer’s system is bureaucratic and slow; there's not a ton you can do to push it through faster. The unfortunate reality is that some of this process is just nudging people at the right times.

Competition and in-housing - There are two vectors of competition for a company like this. One is other companies that help credentialing. There are lots of licensing and credentialing vendors to choose from. Assured’s bet is that by focusing on a specific group right now (companies that have delegated credentialing) and handling the full end-to-end process of licensing through enrollment, they can get really good at this specific process and more easily transfer learnings/automations to similar customers. And they’re betting that they can do this process well.

The second is a company hires someone in-house that’s extremely detail oriented who can stay religiously on top of this process. Part of the question here is going to be your own internal needs as a company. Do you have enough clinicians who need to go through the licensing/credentialing process per year to warrant a full time person? Does it spike (e.g. you expand to a new state) to the point you need overflow capacity? How often do the credentialing vendors miss something in the process vs. how often does an in-house person miss something?

Another part of the question is if that person might devolve into the Joker if handling this is their entire job.

Regulatory shifts - What if…this process just became much much simpler. Like if every payer just decided to use CAQH and you only had to fill it out once for all of them. Or if interstate licensing became mandated and you only had to fill it out once for every state. This was waived during COVID and everyone agreed it was good, which obviously meant we didn’t implement it. Now we get to answer fun power-tripping questions like this!

If the process became much simpler, the value proposition of something like Assured would probably go down. Unfortunately, this doesn’t seem to be happening just yet.

Conclusion And Parting Thoughts

Licensing and credentialing as a whole is a very archaic and outdated process. While going down the rabbit hole and talking to a lot of people that have gone through this process, I wondered why it was still so bad.

One thought is that it’s malicious and on purpose. Payers don’t want providers to get in-network quickly because then they’ll have to pay out bills more quickly, etc.

But the more I look into it, it just seems to be that there’s no incentive to make it any better. It doesn’t help payers to speed up this process, clinicians basically have no choice but to go through this process if they want to get paid, so they do it, and a lot of jobs are dependent on this process being manual. I have yet to hear a convincing argument for why we need licensing in every state, and yet, it’s still the process today.

The people that suffer are the individual clinicians who need to wait to treat patients with a certain coverage, and the patients themselves. 

Even 4-5 months should make us feel embarrassed 

I think one byproduct of generative AI is that it makes tedious form filling easier, and also makes it clear how many processes are tedious form filling. Licensing and credentialing are great examples of this. 

Maybe a company like Assured is the first step into making these kinds of processes obsolete. But even if we’re a long way away from that, at least for now they’re trying to make it so that companies don’t have to deal with this themselves.

Thinkboi out,

Nikhil aka. “James Bond: State-by-State License to Kill”

Twitter: ​@nikillinit​

IG: ​@outofpockethealth​

Other posts: ​outofpocket.health/posts​

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