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Medical Credentialing: A Safeguard Worthy of Significant Support

By Priyankar Bhattacharya, HGS Senior Manager, Provider Network Operations

Today’s healthcare payer and provider organizations are increasingly focusing efforts on physician credentialing for real outcomes such as significant cost savings, turnaround time enhancement, accuracy improvement, and reduced rework. This service area originated in the 1960s, with the Darling v. Charleston Community Memorial Hospital case,  which established the obligation of hospitals to verify their physician and other provider competencies. This landmark ruling led to the creation of the credentialing process as hospitals and other organizations sought to protect themselves from similar lawsuits.

For an inside look at this evolving service, we caught up with our physician credentialing SME Priyankar Bhattacharya, Senior Manager, Process Improvements, HGS Healthcare. Here, HGS talks to Priyankar about this emerging focus and how healthcare credential management is essential to healthcare organizations hiring or obtaining coverage by an insurance carrier.

Q: What is credentialing verification, as provided in today’s healthcare marketplace?

Priyankar: Credentialing is commonly defined as the process of examining, reviewing, and verifying that a candidate’s professional licenses or certifications, education, experience, and other variables are in order and all occupational and related criteria are met. The term is also used with medical groups’ closed panels to determine the eligibility of a prospective provider for clinical privileges at a hospital or managed care organization (MCO). While credentialing appears a straightforward process, it can actually be a difficult and often confusing practice, since many healthcare practitioners require different types of education and certifications.

The act of credentialing, as part of provider enrollment, exists along with other administrative actions that occur once a physician or other clinical practitioner completes his or her education and clinical training. Newly graduated and trained practitioners are often contacted, or put into contact with health system or health plan recruiters, who, in turn, initiate the administrative process by guiding them through the contracting, credentialing, privileging, and provider enrollment process. This ultimately results in a thoroughly vetted clinician who is approved to deliver clinical care, in acute care and/or ambulatory settings, and who can be reimbursed by insurance payers for the associated clinical services

Q: Is this an increasing area of focus for health plans? If so, why?

Priyankar: In today’s litigious society, even the smallest medical misstep can cost hundreds of thousands in legal and medical costs.  Hospitals, physician practices, and other healthcare organizations are increasingly targets of lawsuits, especially when the problems are the result of failure to fully verify the professional credentials of the practitioners and others on their staffs. For smaller practices, this is an especially difficult position, as staffing, time, and other limitations can increase the chances of failing to perform a thorough check of a new associate’s background.

It might seem like credentialing is just a paperwork task, mundane and not as important as patient care; however, it’s an essential task that cannot be taken lightly. It not only protects an organization from potential lawsuits, it’s also a way to ensure practitioners are qualified to do the job they’re being hired to do. It’s a safeguard put in place to protect patients by providing qualified, high-quality health care providers.

Credentialing is not to be confused with “network contracting” or “enrollment,” although it is necessary for insurance companies to also verify professional credentials before adding a new physician or other provider to the organization’s or group’s coverage. Many provider networks and other carriers use the services of Council for Affordable Quality Healthcare (CAQH)  to acquire credentialing data from a centralized location and therefore require that their participating providers have a complete updated profile on file in the system. Hospitals and managed care organizations, as well as individual practices and healthcare staffing companies, must perform strict credentialing due to the possibility of a malpractice lawsuit against a staff member as well as against the hiring organization.

Q: What are the advantages BPOs can bring?

Priyankar: Some of the industry-level bottlenecks that are associated with credentialing are:

  • Low Portability: Lower portability (or, interoperability of data among existing silos) affecting the process workflow and data management tasks in credentialing—translating to less traffic and lag time while seeking response
  • Manual Process: A paper-based and manual credentialing process affects the speed and efficiency of credentialing
  • Data Management:  Inefficient management of data storage, data segmentation, and data security for better credentialing
  • High Error Ratio: High error ratio in the credentialing process due to manual and paper-based systems
  • Noncompliance: Inability to maintain National Committee for Quality Assurance (NCQA) compliance for seamless and secure credentialing process
  • Credential Expiration: Inability to manage and control healthcare credentialing process without proper reminders

BPOs can bring state-of-the-art credentialing solutions or service offerings, including:

  • Centralized credentialing is the process of improving the credentialing efficiency, eliminating repetitive tasks, boost revenue cycle management to stay competitive. Centralized credentialing solutions have a great effect on provider data integrity and in facilitating delegation with payers. With centralized credentialing, two or more than two healthcare facilities share the cost of credentialing providers saving the total cost required.
  • Highly advanced healthcare credentialing solutions help to save the potential waste of huge sums of money by standardizing and coordinating administrative policies and procedures through healthcare credentialing services. Customizing credentialing software solutions helps payers to optimize revenue cycle management and decrease overall expenses.
  •  Workflow automation helps reduce  collecting required data from the physicians, developing the credentialing strategy, auditing the provided data for accuracy, validating the data and certificates, managing provider profiles, and following up with payers. BPOs can customize healthcare credentialing software to replace the manual credentialing workflow.
  • Programming of cloud credentialing software with real-time, intuitive dashboards enhances productivity and eliminates the redundancy in the process. Healthcare credentialing with automated workflows offers a seamless process for online verification, attestation aging, expiration management, credentialing metrics, onboarding options and more.
  • Demographic analytics are optimized with custom-made credentialing software solutions that provide an insight view of the process, workflow, and process of credentialing at a specific healthcare facility. The cloud-based data storage and data management features help in maintaining the optimum quality of the gathered data securely. BPOs can help program tailored credentialing software that replaces the practice of maintaining the myriad of spreadsheets and files to store credentialing data.
  • Multi-tier database hierarchy, intuitive database population, and timely provider and payer updates help you to develop an advanced credentialing infrastructure where data is segmented based on healthcare facility, groups within the facility, locations, departments, and provider specialties. The right BPO can engineer credentialing software solutions to ensure credentialing services operate to provide maximum success.
  • Online provider verification is among the essential healthcare credentialing services that streamline the process of online validation of the provider’s submitted credentials and certificates. Cutting-edge cloud credentialing software helps in assessing and acquiring accurate, current information regarding physicians and healthcare providers including nurse practitioners, labs and skilled health nursing facilities.
  •  The expiration reminders and automated alerts in insurance credentialing software can help to keep track of documents and certificates that are about to expire and changes in performance metrics. Custom credentialing tracking software helps in providing complete visibility in the provider’s profile with smart notification settings and automated email reminders.
  • Unlimited, intuitive, and comprehensive credentialing reports can query and recover insightful data and customize reports in a variety of formats.

Ultimately, BPOs can address all pain points with the people, process, and technology targeting credentialing challenges, including engineer credentialing tracking software that incorporates top-quality reporting features including institutional summery, days in enrollment, facility summery, provider summery and more. These service partners can program made-to-order credentialing software solutions that provide a comprehensive library of ad-hoc reporting, built-in reports, summary management reports tickler reports, board certification, and reappointment data.

With a dedicated credentialing focus, organizations can ensure that patients are receiving the highest level of care from healthcare professionals who have undergone the most stringent scrutiny regarding their ability to practice medicine. Providers can be assured that colleagues are being held to the consistent standards, with the right priority in place: the quality of patient care.

Author Info
Priyankar Bhattacharya
Priyankar Bhattacharya

Priyankar has more than 13 years of U.S. healthcare experience spanning various aspects of the value chain like policy management, claim adjudication, network operations and procurement, pre-authorization, and customer service operations. He has worked for major U.S. and middle east global healthcare payers. He is a certified Six Sigma Black belt from ISI Chennai and has accomplished over five black belt projects.

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