Standardization is Needed for Credentialing and Provider Enrollment (Part 1)

April 1, 2021
April 1, 2021

This blog post excerpts an article by Linda Waldorf BS, CPMSM, CPCS; President, Board of Directors,

National Association of Medical Staff Services (NAMSS)/ Director of Centralized Credentialing Office and the Office of Medical Staff Services (OMSS), UNC Health Care System, Chapel Hill, NC in the Q4 2015 issue of PX Advisor, our quarterly magazine designed to bring you thought leadership and best practices for improving the patient experience.

Increasingly, the field of credentialing and provider enrollment is becoming more complicated. As more physicians become employed, there is a greater demand on hospital staff to get providers onboarded, credentialed, and enrolled in payer plans in a timely manner. Even more challenging is the fact that every payer and regulatory agency has its own unique set of application requirements.

In my role as both NAMSS president and a credentialing leader at UNC Health System, I am viewing these issues from several perspectives. In this article, I would like to provide an overview of some of the new complexities with credentialing and provider enrollment and make a case that standardization is urgently needed.

The Complexities of Credentialing

For years, hospitals have considered provider enrollment and credentialing to be complex, repetitive, and time-consuming processes best left to the back-office staff. However, recent industry developments have escalated the importance of these processes and brought them to healthcare leaders’ attention. Leaders are realizing the link between these administrative procedures and significant revenue losses. With increasing pressure to find a solution to this dilemma a major question arises—why is there still no standardization in provider credentialing and enrollment? Currently, credentialing, onboarding, and enrollment processes are treated as three separate functions within healthcare organizations. Countless hours and millions of dollars are lost as doctors and administrators file redundant contracts between providers and health plans. In order to make advancements, increased integration of these three processes must be made, significant improvements in technology for reporting and data solutions are needed, and, most importantly, standardization in this field must be achieved. This problem has been on providers’, hospitals’, payers’, and the government’s agenda for years, but the situation is dramatically coming to the forefront as healthcare organizations are hiring large numbers of physicians and assuming a heavy paperwork burden. The push for more transparent and frequent credentialing, the use of telemedicine, and the increasing use of emergent disciplines are now contributing to the demand for standardization in credentialing and provider enrollment.

The Growing Push for Transparency

With ever-increasing access to information through technology, the push for transparency in the credentialing process is growing. In the past, simply running a background check on a physician was considered adequate. Now, the options are endless. Should drug testing be mandatory? Does the escalation of the number of new medical devices require training covered by the credentialing process? And what of the growing number of public databases containing sensitive information about patients’ experiences with physicians? 

The Need for More Frequent Credentialing

Medical Service Professionals (MSPs) are committed to ensuring quality and patient safety in the midst of the ever-changing environment of healthcare facilities. NAMSS supports The Joint Commission processes of Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) in their efforts to regularly evaluate practitioners. OPPE is even becoming a new credentialing element in itself that is capable of continuously monitoring practitioner performance. Hospital leaders are increasingly asked to do more with less in regard to ongoing monitoring but are struggling with how to do it. The variation in what can be measured across specialties is enormous; for instance, consider the differences between the practices of a dermatologist versus a neurosurgeon. In addition, some hospitals may maintain 50 different specialties on staff and are trying to find the best way to measure performance and improvement across such varied disciplines. More frequent credentialing is needed to support quality and patient safety—without standardization in the process, this only means more time and money spent.

This article also includes:

  • The Impact of Telemedicine
  • Emerging Disciplines That Demand Support
  • The Desperate Need for Standardization