Credentialing management solutions: Maintaining compliance and planning for growth


For any healthcare organization, proper credentialing is a critical component of maintaining compliance, ensuring qualified providers are in place to deliver quality patient care and sustaining consistent cash flow. Document acquisition and verification, enrollment with insurance payers, and facility privileging may seem like straightforward credentialing processes. However, rapid changes in healthcare have increased the complexity of these requirements for organizations of all sizes.

Consolidations between insurers and providers, increased emphasis on the patient experience, the expansion of Medicare Advantage and the future of the Affordable Care Act have all influenced the demands of credentialing. As a result, organizations may struggle to navigate a constant cycle of renewal dates and verifications from health plans if they lack an efficient credentialing system, relying instead on time-consuming, manual processes that can add additional strain to tight budgets and resources.

Inefficiencies that inhibit organizational growth
Employing dedicated credentialing experts that use paper-based or spreadsheet systems makes it difficult to replace exiting long-term credentialing staff – a mounting concern as employee turnover rates in healthcare continue to rise. A lack of experienced staff that understands the complex nature of the credentialing process can lead to the loss of critical information, delays and noncompliance issues. If you do find a qualified candidate, it may take six months or longer to sufficiently evaluate his or her performance; and if your hire does not perform well, you could end up spending valuable time correcting errors and gathering missing information. Meanwhile, new credentialing functions would typically build up, making the workload unmanageable.

Additionally, the marketplace is experiencing a record number of mergers, acquisitions and expansions as health and hospital systems look to reduce costs, provide a wider range of services and transition to new models of care. However, these transactions often lead to major issues when the companies try to connect their disparate, manual systems. Organizations with strategic growth plans will realize that a traditional in-house credentialing management department lacks the capacity or flexibility to effectively keep up with the growing number of providers, which limits the companies’ abilities to scale. For example, one organization looking to expand into additional states had a very competent credentialing team in place, but they still used Microsoft Excel to track each step. All document acquisition and verification was done by hand, each payer enrollment form completed manually and re-credentialing alerts were set as calendar reminders in Outlook. It was virtually impossible to maintain this type of “old school” credentialing department while supporting the organization’s aggressive growth.

Today, the risk is much too high from both a business standpoint and a legal perspective to not invest in better technology and processes. Medical errors, litigation exposure and audits from accrediting bodies make it critical for organizations to ensure that providers are qualified, educated, licensed and certified to provide services to patients. Otherwise, loss of immunity from lawsuits and decreased revenue can result.

Automated credentialing
Having the right technology in place for your health system can alleviate the administrative burden on staff, maximize revenue and keep the focus on providing patient care. An automated credentialing solution used in place of Excel and Outlook can rapidly complete credentialing requirements, fill out and customize payer enrollment forms, and set real-time notification of events, deadlines and ongoing primary source verifications. Credentialing software can also streamline audits, re-credentialing, and reporting for individual providers and the organization as a whole.

Healthcare practices considering a new credentialing technology solution should determine their precise needs prior to having discussions with a solution provider. With so many options on the market, it is too easy to end up with an incomplete solution if you are not methodical in identifying necessary features.

Here’s what to look for in a quality credentialing software solution:

1. Ease of use: Look for intuitive, user-friendly software with an automated format that provides all credentialing functionality for you.

2. All-in-one capabilities: Avoid software options offering primary source verifications only, and have no payer enrollment functionality or document storage. Find a solution that organizes all information within one portal and provides instant access to crucial information and reporting. An all-in-one solution also ensures that providers can easily maintain compliance with regulatory, accreditation and licensing standards.

3. Self-managed vs. fully managed options: Avoid credentialing software platforms that do not allow organizations to outsource credentialing responsibilities, and only serve as an online depository for records. Practices that lack the resources for an in-house credentialing team should choose an option that will allow them to outsource full responsibilities to an experienced third party. This allows each step of the credentialing process to be handled by a dedicated expert.

4. Vendor expertise and stability: With ongoing market disruption in the healthcare technology industry, be sure to choose a credentialing management partner with a solid reputation for reliability, expertise and stability. This will guarantee the long-term success and accessibility of your credentialing management solution.

Ted Gottis
Ted Gottis is senior vice president of the MedTrainer, Inc. – QuickCred division.


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