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Credentialing Issues in Healthcare

Credentialing is the process by which organizations obtain and evaluate documentation regarding a medical provider's education, training, work history, licensure, regulatory compliance record, and malpractice history before allowing that provider to participate in a network. Provider credentialing is foundational to healthcare and is clinically and financially essential. Credentialing mistakes can result in increased legal liability and delayed or lost revenue.

Issues and Challenges to Successful Credentialing Programs

1. Evolving Requirements - An evolving business environment, such as healthcare, means changing requirements in how healthcare organizations manage their credentialing processes. Public reporting and increasing levels of scrutiny led the National Committee for Quality Assurance (NCQA) to develop a set of standards that now drive the provider credentialing process. Their requirements have added some rigor to the process by requiring that the organization verify with the primary source when verifying degrees, diplomas, or certificates. Copies are no longer sufficient to satisfy the requirement. Having people and processes that are committed to addressing the evolving nature of credentialing along with the increasingly rigorous requirements is essential to the accuracy and efficiency of the process.

2. Resource Requirements – Payers and other organizations that supply the information that is critical to the credentialing process have their own standards for processing requests. Because these timelines are different from one another, and in some cases, longer than what we might anticipate, it is difficult to estimate completion dates for credentialing. This can make tracking provider progress through the process somewhat difficult.

Even if the information required for credentialing is made readily available, the process is still fairly laborious and requires real attention to detail and a great deal of work, disciplined processes and meticulous record-keeping. Having software and processes dedicated to credentialing can help minimize errors and shorten timelines.

3. Managing Additional Requirements – Your organization may be in a state that has additional credentialing requirements. Make sure that credentialing staff understand the unique requirements of your location and that any additional steps that might be necessary are built into your processes. Credentialing software should also address the unique requirements of your state.

4. Failure to Address Requirements for Updates – Providers need to update their licenses and other credentials regularly according to the requirements of the state in which they are practicing. In addition, processes to capture interim changes in information like phone numbers and other contact information must be in place. Processes that are systematic in

tracking required updates and people who are attentive to detail in their management of these processes are critical to the success of a credentialing program.

5. Incomplete Provider Applications – The credentialing process can be daunting for the provider as well. The applications can require enormous amounts of information and incomplete information may cause an application to be rejected. Software and processes that verify full and complete applications can make the process faster and more efficient.

In the midst of continual healthcare change some things stay the same, like the need for comprehensive provider credentialing, privileging, and enrollment processes. In today’s value-based environment, operational efficiency is critical. Conducting manual verifications, completing paper forms by hand or taking time to deliver files to various locations across the hospital or the system is not cost-effective. Learn about making VerityStream your comprehensive provider solutions partner.


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