Healthcare credentialing refers to the process where medical organizations verify providers’ credentials to make sure that they have the necessary licenses, certifications, and skills required to provide proper care services for patients. It is also known as physician credentialing, medical credentialing, or doctor credentialing. Healthcare credentialing is usually associated with authorizing physicians, but similar practice management systems are implemented for nurses and other healthcare providers.
Healthcare providers should go through credentialing to enrols and attest with the Payer’s network. Additionally, healthcare credentialing also authorizes clinicians to offer services to patients who are a part of Payer’s plans. The credentialing process is a way of checking whether a physician meets the standards established for delivering clinical care. Payers may choose to delay or refuse payments to doctors who do not have the required healthcare credentialing, which can have adverse financial consequences.
The manual process of healthcare credentialing is tedious and time-consuming. Considering the paperwork involved, it can take 2-3 months to complete the physician credentialing process. Complex applications, arduous reviewing, stringent background checks, cross-checking procedures, and validation of licenses and certifications are many processes involved in healthcare credentialing. Due to the nature of the healthcare industry, these are all critical requirements for quality maintenance and provider risk management.
If your healthcare organization struggles to manage these complexities and pays a whopping cost toward these services, it’s time to consider process automation. Healthcare organizations will not obtain reimbursement for provided services from insurance companies if they lack medical credentialing. In the absence of healthcare credentialing, it can be not easy to work with any software solutions. It must not be ignored by any provider who intends to achieve high patient flow. Healthcare credentialing can manage your ROI generation and help keep track of your medical credentials.
2. Challenges of healthcare credentialing
We have prepared a comprehensive list of roadblocks regarding medical credentialing. This would help you gain insight into the potential issues you may face with healthcare credentialing to avoid them.
There are many potential issues and consequences in the healthcare credentialing process. Provider credentialing is considered a major compliance issue in medical practice. In the lack of process oversight and data insight, errors may occur in a credentialing service, resulting in severe consequences.
Mistakes happen in any healthcare operational process. However, mistakes in the credentialing process can cost an individual’s license or affect your organization’s reputation. Incomplete credentials are of utmost importance in the healthcare industry, and Poorly-run credentialing companies may lead to enrolment issues, along with legal and financial complications.
We have listed the most common challenges in the medical credentialing services for providers below:
a. Timing and planning
The provider credentialing process involves the verification of large volumes of data, which can take around 3-4 months to complete. The collection and preparation of relevant documents for the application may take longer than the estimated timeline. If you fail to plan for this time lag, it can affect your facility and its services. Healthcare providers may also have to wait to start consulting. Until a new practitioner is credentialed and enrolled, the medical credentialing companies cannot reimburse the bills from his/her services. This can cause serious revenue losses to the healthcare organization. Lack of planning regarding the timeline required for processing a healthcare credentialing application is a common mistake that providers need to watch out for.
b. Data entry errors
Data entry mistakes are common in the credentialing process, and this can have severe consequences, such as delays and payment refusals. Take a look at the most common credentialing errors:
Occurs during data entry, when wrong or interchanged information can lead to confusion while entering the data—wrong or interchanged information leading to confusion. If you cannot recheck the data entered for spelling mistakes or wrong license numbers, it may cause unnecessary delays.
d. Missing information
Lack of relevant data or omitting a much-required document due to confusion is another common healthcare credentialing mistake that should be avoided while manually assembling the documents.
e. Improper documentation
Mishandling important documents or not keeping them organized can cause ambiguity and confusion in the entire credentialing application process, often requiring resubmission.
Mistakes in the healthcare credentialing application process
The list of errors under this category includes:
i. Incomplete application
Healthcare credentialing applications are usually labelled as incomplete and rejected. This is particularly true if any part of the application is left blank or relevant supporting documents are not submitted. Providers should assemble all documents highlighting their career history from getting licensed to verification date. Any missing documents from this period may produce confusion.
ii. Improper authorization
Healthcare credentialing applications may lack the required signature and attestation from the respective individuals involved. Such mistakes can lead to rejection of the application altogether
Results when there is a time lag while handling queries raised by the authorities regarding the application. This can obstruct or delay the entire credentialing process. Mostly, the questions remain unanswered by busy clinical staff members.
iv. Failing to track the application status
After the credentialing application is submitted, there is scope for it to get stuck or delayed. Sometimes, there is negligence due to failure to follow up and track your credentialing application, delaying the process. As a result, there is a loss of time and revenue in leu with awaiting updates from the insurance companies.
v. Accessing Updated Information
Providers may struggle to access patient information, with nearly 85% of credentialing applications containing inaccurate, missing, or out-of-date information. Small changes, such as in address or phone number, must be attested in the CAQH database before a care source provider enrolment application can be processed by the system.
Factors that can impact the credentialing process include missing documents, training details, or incorrect data. Such issues can quickly turn the process of credentialing health care providers into a cumbersome task. This issue commonly occurs when credentialing doctors regularly move around from one healthcare institution to another, and organizations need to track the changes.
vi. Meeting Deadlines
Healthcare credentialing can be a major hindering component of the revenue cycle of your healthcare organization. Application review in the provider credentialing process itself can take upto 90 days for an organization to complete. However, with additional stakeholders, like insurance companies or contract negotiators, medical staff credentialing can actually take up to six months, which can further stall your organization.
vii. Inability to Switch Platforms
As your credentialing in healthcare program expands, and the requirements become more complex, you may need to add integrations or change assessment platforms completely. However, suppose there is a lot of content on your platform, such as preset questions or prompts, and these are not standards-compliant. In that case, the migration process in healthcare credentialing can become impossible without losing one component or another. Thus, many medical credentialing companies get stuck with outdated platforms that restrict the healthcare credentialing process.
viii. Compliance with State Regulations
Each state has its own healthcare credentialing standards and medical services policy guidelines. Additionally, certain national organizations like CAHQ specify requirements for payer credentialing. This gives rise to issues in healthcare credentialing because the requirements may vary among different states and also with modified policy or legislature. Your medical provider credentialing platform must be updated with the changing regulations, and incorporate new requirements as they take place in real-time.
ix. Implementation Data Privacy and Security
In healthcare credentialing, background checks are an essential aspect of the process. Apart from eligibility requirements, like degrees or previous credentials, background checks make sure that the applicant adheres to national licensing requirements. Privacy and security are crucial in this step of the process of credentialing for doctors and forward.
The doctor’s entire history regarding malpractice, board actions, or reports to the National Practitioner Database should be evident to the healthcare credentialing organization and insurance agencies. Suppose physician credential companies are unable to disclose incidents and backlogs in the system, or lack real-time data. In that case, it can all result in rejection or worse, legal implications for the applicant or the credentialing party. Your health care credentialing platform must communicate with various databases to keep that information secure and up-to-date.
x. Simplify the medical credentialing process
Healthcare Interoperability standards enable physician credentialing companies to achieve healthcare objectives credentials and results in the healthcare credentialing process. It can eliminate many challenges in the provider credentialing process.
3.Types of Credentialing
Medical credentials have various types, and knowing these would enable you to better understand the entire process. Here, we have enlisted and briefly explained each type.
Every healthcare organization needs to carefully evaluate their credentialing requirement to gauge whether they would prefer the manual process or if they would benefit from automating physician credentialing. In most cases, automation in physician credentialing is the preferred option, owing to its advanced capabilities. Below is a detailed description of both sides of the coin for increased clarity.
The manual process of healthcare credentialing involves the following steps
- A designated full-time credentialing team
- Large volumes of paperwork for filling and filing
- Complex processes of back and forth for information collection and dispatch
- Submissions for approvals
- Periodic renewals of licenses and certificates
The processes mentioned above take far longer to complete and take the complete process far longer, approximately 2-3 months. Any error along the way can result in a severe impediment and sometimes disastrous results. Finally, the traditional way is no longer in tune with a speedily developing landscape of technologically dynamic healthcare processes.
Now, credentialing automation will undertake the steps mentioned above, but in a robust, swift, and optimized fashion. Healthcare providers stand to gain a considerable competitive advantage through an automated credentialing process. The benefits of healthcare automation in practice management, electronic data exchange, population health management, patient engagement systems, and medical records management are visible across the industry.
With the onset of automation in digital credentialing, the following processes can be optimized
1. Application of medical informatics to create intelligent workflows for collection and verification of physician information.
2. HIPAA compliant solutions for the security of healthcare data
3. Healthcare analytics solutions towards the submission of physician credentials
4. Reference checks, malpractice security, criminal record checks, etc., through cloud computing in healthcare.
Even though certain process elements may fall outside the purview of credentialing automation, a significant chunk of the credentialing process can be swiftly achieved through provider credentialing software. A manual process that generally takes 60-90 days can be completed in 6-7 days through automated credentialing in healthcare staffing.
A. Integrated Healthcare Credentialing Software
Integrating applications and platforms toward creating agility and performance is the new mantra of healthcare management. Integrated healthcare solutions are the need of the hour, and credentialing software is no exception. By infusing integration and automation into the credentialing process, can bring substantial advantages to the healthcare organization. Healthcare interoperability solutions can be applied toward medical staff credentialing software for considerable quality enhancement, time management, and cost-effectiveness. Finally, a fully integrated workflow healthcare automation solution can optimize turnaround time, enhance physician experiences and compliance.
With the current approach of value-based caregiving, healthcare credentialing software can be the game-changer towards optimized processes through automation for quality assurance and risk reduction. As healthcare professionals speedily get on board, patient experiences and satisfaction are maximized.
B. New Registrations/Renewals of an Individual Provider
This applies to new registration of physicians or renewals of their credentialis with the State or with the Drug Enforcement Agency (DEA)
C. Provider Data Maintenance
It includes provider demographic update and provider directory maintenance on payer sites.
D. Contract Creation and Maintenance
This type of healthcare credentialing is applicable to new groups or individual practitioners, adding or deleting the current contract, or adding or making changes in the existing contract, and negotiation of costs.
E. CAQH Attestation
The Council for Affordable Quality Healthcare, Inc. reduces redundant and inefficient administrative processes between health plans and providers. This is true for credentialing, directory maintenance, and other essential healthcare functions. CAQH attestation involves CAQH application filing and quarterly attestations.
F. Expirations and Renewals
This type involves tracking expiry dates for State DEA License, Board certificate, and Malpractice Insurance
G. Tracking and Analytics
It is a healthcare credentialing that is responsible for maintaining a repository of provider credentialing documents, contract agreements, and tracking credentials. This also involves the denials team confirming whether any claim denial issues have arisen due to credentialing.
4. Why choose Software Automated Credentialing
This section provides a detailed explanation of the benefits of automated medical credentialing software. These points highlight why manual credentialing must be replaced with an automated process.
Healthcare Automation to the credentialing process could not have arrived at a more prudent time. It is strategically capable of reducing complex credentialing workflows, managing revenue generation, and speeding up operational demands. Embracing this automation technology will ensure optimization, efficiency, and agility and secure your health facilities’ position within a highly competitive landscape.
1. Streamlined Processes
Process automation in credentialing can reduce manual time spent on the job by up to 3-5 hours a day to fill in rigorous paperwork. An automated credentialing platform integrating electronic health records with physician records can offer advanced efficiency by eliminating redundancies and errors. Medical credentialing software collates data from multiple sources and stores it on a central platform for quick retrieval and efficient management. The automated checks, alerts, and notifications can save hundreds of hours in manual labour and get the job done with higher efficiency.
2. Decreased Complexities
Electronic medical credentialing software for physicians automatically reduces the paperwork involved with manual processes. Not only are credentialing staff free of paper-based processes, but providers no longer need to fill out lengthy paper forms. Automating physician credentialing can incorporate credentialing into their purview for all-rounded service offerings. Automation to the credentialing process offers increased accessibility to provider qualifications. Moreover, virtual meetings can be organized to assess provider credentials across multiple locations with automated medical credentialing services.
3. Reduced Operational Costs/h3>
According to a recent study, automation of the credentialing process can save a health facility approximately $30,000 annually. Costly processes have a devastating effect on healthcare organizations and stagnate them from moving ahead in the game. An automated credentialing process is a sure shot way to reduce the cost of manual processes drastically. Adopting healthcare automation solutions is an essential matter for all organizations to mull over. Tailor-made software credentialing in healthcare allows the health facility to choose the features relevant to their own specific needs. Based on specific requirements, cost-efficient software can be developed to address suitable needs. Deployment of automated health systems may require a start-up cost, but it offers significant cost savings in the long run.
4. Increased Viability
Automation for healthcare can be applied to physician credentialing software to ensure compliance with the healthcare credentialing regulations and requirements. Deadlines and renewal requirements are accessible through reminders in credentials automation. Automated tracking of licenses, certificates, and other relevant information about providers can be a handy tool. Providers who are already on the system can update their certifications and licenses with ease. Tracking and reporting can also lend themselves toward information on medical incidences, including red flags.
5. Reduced Errors
According to a recent study, medical errors are responsible for over 95,000 deaths across the U.S. This is where automation of the credentialing process comes into play. Healthcare professionals and facilities can ensure patient safety and security with the appropriate protocols, licenses, and certificates in place. An automated credentialing data management solution that offers healthcare interoperability and integrated care management can minimize or even eliminate the possibility of medical errors. In the larger scheme of things, this approach benefits the healthcare industry as a whole. The bottom line remains that patients look for healthcare providers that know their job and will undertake it safely.
5. Credentialing standards in the US
Here, we have discussed the medical credentialing standards applicable in the US. Healthcare organizations in the US need to comply with these to avoid problems.
The federal Centers for Medicare & Medicaid Services (CMS) and the Joint Commision on Accreditation of Healthcare Organizations both require that healthcare providers be credentialed. Healthcare organizations that don’t follow the CMS regulations are not eligible for Medicare or Medicaid reimbursement. Similarly, the Joint Commission accredits only those who follow its regulations. Most U.S. hospitals pursue the Joint Commission accreditation, which is required for Medicare and Medicaid reimbursement eligibility. States also have their own regulations.
Other groups set standards on credentialing as well, and many healthcare organizations follow them to receive additional accreditation. Those groups include the following:
- The National Committee for Quality Assurance (NCQA)
- Utilization Review Accreditation Commission (URAC)
- The Accreditation Association for Ambulatory Healthcare (AAAHC)
- Det Norske Veritas (DNV)
6. Phases of credentialing
The process of medical credentialing is fairly complex, and it can be divided into different phases. We have explained each phase of the cycle separately for easy understanding.
The process of medical credentialing is fairly complex, and it can be divided into different phases. We have explained each phase of the cycle separately for easy understanding.
There are three main primary phases of healthcare credentialing are as follows:
1. Acquire Information
- A healthcare organization or health insurance plan requests the provider for Information on his/her background, licenses, education, etc. The healthcare provider can submit the data requested in the questionnaire through healthcare credentialing software.
- Sometimes, the healthcare facility or insurance company is associated with a third-party company, known as the credential’s verification organization. This healthcare credentialing process helps to acquire and verify Information. Healthcare organizations often hire CVOs to promote efficient medical credentialing.
2. Prioritize insurers
- This step is crucial, where you will need to submit multiple applications, and it can be beneficial to prioritize them.
- If a major component of your medical billing is processed by a single insurer, then complete their healthcare credentialing first.
- Be acquainted with individual insurer regulations because some insurance providers allow a smooth process for providers already insured in another state, and this may speed-up the process.
- Whereas, some other insurance companies offer an abbreviated application for healthcare providers credentialed within the State.
- It is advisable to enlist your priorities and start arranging the documents and applications.
3. Verify the Information
- When physician credentialing companies conduct the background work, they will directly correspond with licensing agencies, medical schools, and other entities to check the provider’s Information.
- The facility or insurance company may utilize medical credentialing software to verify Information that licensing agencies and other entities make available online. The CVO may also be involved in these verification checks.
- Many healthcare organizations use collaboration and practice management to help them record provider information. The medical credentialing system provides automated updates when certain credentials expire or need to be re-checked.
- In all cases, the checks consist of monitoring reports about medical incidents, malpractice claims, or other Information that can give clarity about whether to credential or re-credential the provider.
4. Finish the CAQH
- Many healthcare insurance companies require providers to aply for credentialing through the CAQH.
- Once you have filed an application for an individual insurer, you will receive a CAQH number along with an invitation to apply.
- Healthcare providers will have the option to complete the CAQH form on paper or online.
- CAQH approval can be delayed due to inaccurate or missing Information.
- Once the initial application is submitted, it must be re-attested to maintain continuous insurance eligibility.
5. Wait for verification of documents
Once the credentialing application is assembled and submitted to insurers, it is time to wait for their approval, which can be time-consuming. Most healthcare credentialing can complete within 90 days; it is advisable to give a leeway of 150 days.
- It is not a good idea to wait for months together to hear from an insurer. Provider credentialing requires consistent follow-ups for timely approval.
- Build relationships with key personnel at the insurance company.
- Check-in using a smartphone rather than email to maximize the chance of a response.
- If you learn that additional Information is required, then compile and verify all documents in a timely manner.
- Felicitate the Provider with Credentials
- Once the provider credentials are verified, and it is all-clear, the insurance company will award the provider with his/her credentials.
- The healthcare insurance company can decide whether or not to approve the provider as an in-network provider. That is, the insurance company will pay the provider for treating patients who have its insurance.
- Once you receive your healthcare credentialing, there is no guarantee it is lifelong. Credentialing is an ongoing process that requires continuous work.
- If you find an error in the Information, it is important to notify insurers. This is important because if they notice the erroneous Information before you submit a formal correction, it could be grounds for revocation.
- Most providers need re-credentialing once every three years.
7. Features of healthcare credentialing software
When choosing a medical credentialing solution, it is important to know the features that will serve the purpose of integrating it into your practice. This section consists of a broad list of features that support successful healthcare credentialing software.
Various credential software systems are available in the healthcare market that offers different features to choose from. It may be confusing which feature is ideal for you, which is why we have prepared a comprehensive list of 10 features:
A. Centralized Credentialing
It refers to a process where two or more healthcare providers can manage the costs by dividing the entire cost of credentialing providers. In such cases, the healthcare providers need to implement a lengthy credentialing process just once. It works as both a time-saver and helps to foster better patient-provider relationships. Another benefit of centralized credentialing is the enhanced credentialing efficiency supported by easy communication with payers, improved data integration, and overall higher ROI generation.
B. Cloud-based System
A cloud-based network provides portability if you choose credentialing software that allows the storage of data on the cloud. This also enables providers and other users to utilize the system on any smart device backed by data security.
C. CAQH Integration
The Council for Affordable Quality Healthcare (CAQH) is a non-profit association of health insurers responsible for data collection and maintenance of provider credentialing data. A credentialing system containing provider credentialing details from CAQH can simplify data sharing with multiple health plans and fast-track the whole process.
D. Workflow Automation
Medical credentialing consists of various steps, such as data collection from providers, creation of credentialing strategy, verification of credentials, management of provider profiles, and contacting payers. A credentialing software automates each of these steps through dashboards and onboarding options. It saves time and ensures accuracy and efficiency in the entire medical credentialing process.
E. Document Expiration Management
Healthcare organizations are utilizing manual credentialing struggle to update provider data and credentials regularly. This task is automated and simplified by credentialing software that enables easy tracking of provider data along with certificates and documentation. Providers are notified through alerts and reminders about documents reaching expiration, so they can take the necessary actions timely.
F. CME Tracking
Physicians and other healthcare providers solutions need to constantly update their knowledge and skillset to meet the growing health concerns. This makes tracking continuing medical education (CME) difficult and time-consuming. While selecting a credentialing software, providers must opt for a system that offers a streamlined process for earning, tracking, and viewing reports on CME certifications, points, and other relevant accolades.
G. Electronic Forms and e-Signatures
The credentialing process involves tonnes of documentation work and some of them require signatures. Instead of waiting for medical consent forms or signatures, it is advisable to look for credentialing software systems offering electronic forms and e-signatures. In this way, you can easily access and upload documents and sign them or receive consent signatures within a short span of time.
H. Automation of Peer Review
Medical peer review is a process that helps to enhance the quality of patient care delivery. It measures and compares the performance efficiency of the previous and existing colleagues. The peer-review process ensures that the quality of care and accuracy is maintained. Choose a credentialing software that automates feedback collection from peers and simplifies the review.
I. Secure Data Management
Credentialing data is valuable and needs to be managed efficiently to avoid data loss or data theft, or other problems. If manual credentialing is applied, the providers may struggle to accurately manage the data and safeguard the information. This is where custom credentialing software comes in handy. It can offer end-to-end functionality that manages all aspects of data, from storing to segmentation and security.
J. Custom Reporting
A credentialing software can greatly simplify reporting, where providers can create, view and store reports. They can visualize the reports to understand the parameters that affect the workflow process. Details, such as days in enrolment, a summary of the facility, provider information, and so on, can be added in custom reports.
An efficient credentialing software should also comprise the following checklist:
- Offer the option to connect credentialing on cloud, which supports secure access of documents from any device by representatives and providers —
- Implement provider credentialing information from the Council for Affordable Quality Healthcare (CAQH).
- Track and monitor credentials for healthcare providers, including nurses, physician assistants, physical therapists, and mental health providers.
- Automate updates and warnings on upcoming expirations of certificates or need for renewal of credentials.
- Track ongoing medical education requirements.
- Integrate a simplified process for peer review
- Educate and update the staff within a short time period.
- Build a user-friendly interface consisting of a dashboard, graphics, and drag-and-drop capabilities.
- Include ample space for storing and managing credential data.
- Allow the use of electronic forms and e-signatures.
- Produce customized reports.
- Integrate with word processing software that support letters and documents.
- Incorporate user-friendly email software for easy communication through the system.
- Improve the overall workflow that promoted the generation of work lists and follow-up requirements.
- Meet credentialing requirements from the Joint Commission and the National Committee on Quality Assurance (NCQA).
- Display hospital privileging information.
- Provide 24/7 customer support.
Many features of credentialing software are focused on the basic aspects, but the specific attributes and the checklist can ensure your provider credentialing software will improve the efficiency of the medical credentialing process. Among the most important features listed above, it is important that the software provides digital access to medical licensure boards. This would support automated track licensing, certificates, and other information about a provider.
8. Questions to ask before choosing a healthcare credentialing software
Selecting the right medical credentialing system can seem exhausting, but it is crucial to ensure that it runs smoothly. This section will guide you through the questions you need to ask the vendor to avoid choosing the wrong software.
When sourcing for credentialing software, it is important to ask the provider credentialing companies some questions. We have prepared a list of some basic to detailed questions you can begin with:
1. Can we email a link to peer references using the healthcare credentialing solution?
It is important to know whether medical credentialing software can make your life easier. Sending faxes or emailing documents as attachments is the need of the latest century. In this way, you will know if healthcare credentialing offers what you need through a simple click to an online form.
2. Will peer references be able to submit information online from any smart device?
It is a fact that these days, people are glued to their phones and tablets. Given this fact, it is crucial that the credentialing is compatible with a smart system that can be accessed away from the office.
3. Does the medical credentialing solution offer online error verification to make sure that peer references are complete?
This verification avoids delays and repeated requests for information. With a provider credentialing, mistakes and omissions can be found before the peer reference clicks send.
4. Can the credentialing software integrate electronic signatures to validate the authenticity?
When using a healthcare credentialing system, it is beneficial to sign, scan and email them. If the medical credentialing software supports electronic signatures on documents, then it can save a lot of time.
5. Does the credentialing solution automatically send reminders to those who haven’t responded?
This would mean no need to schedule regular, manual reminders. You can save time with automated reminders.
6. What is the cost of healthcare credentialing?
Price is the main criterion when it comes to choosing the healthcare credentialing vendor. It helps to decide the budget and select the right quote. An efficient credentialing software vendor will flex a bit on the price, but make sure you do not opt for an overpriced healthcare credentialing solution. Search for a software partner who offers automation and provides the best practice approach for the implementation and optimization of insurance credentialing services.
7. Does the credentialing software offer simple to use and functionality?
Flashy, new, fun. Flashy and fun elements on a dashboard may be great to look at, but are they easy to use? It is important to question the user interface and get clear answers. Verify the custom fields the ability to create and run reports, web crawlers, and schedulers that auto-run. Understand what is necessary for your healthcare organization and target users.
8. Does healthcare credentialing provide long-term scalability?
While selecting a healthcare credentialing software, it is important that you know if it is scalable for the long term. If you’re unsure, then ask the vendor and share them with the vendor. If the credentialing company is unable to explain to you how the product can be scaled or configured, then it is not the right choice for you.
Regarding the functionality of the credentialing software, find out its availability, how it will work, and whether the vendor will connect you with a developer for questions.
9. Does your representative or a partner approve of the software?
You need to compare at least two solutions for your due diligence process. It is time to make the right decision, and the choice may come down to minor differences. An experienced sales representative will let you know the difficulties while making a choice. Talk openly to your representative and consider his/her opinion while making the decision.
9. Healthcare Credentialing Trends in 2023
This section consists of a brief discussion of the trends in medical credentialing that is expected in 2023 and possibly, the years to come.
The COVID-19 pandemic significantly impacted the healthcare credentialing software market. In 2023, the global health care credentialing market is expected to grow, and this will continue till 2027. The healthcare credentialing market will expand at a steady rate this year and will witness an increase in the adoption of strategies by key players.
The pandemic introduced many changes in the healthcare industry, which fast-tracked innovation and brought to light a better way of achieving goals. Many healthcare organizations have reacted quickly to create new technologies due to the challenges of COVID-19. However, technology simplified various healthcare operations, and provider credentialing is no exception.
We have prepared a list of the top healthcare credentialing trends in 2023:
i.Modernized healthcare credentialing
Credentialing in healthcare is significant in managing the workforce demands of COVID-19, and it consists of lengthy, complicated, and costly processes if done manually. Managing credentials for providers within a practice management or hospital management can be lengthy, complicated, and costly if done manually. Healthcare credentialing with technology allows physicians to cross state lines or switch organizations easily. However, as per recent research, providers and patients like telemedicine, which is why finding ways to perform healthcare credentialing for telemedicine solutions timely, is crucial. The healthcare credentialing software enables to make the entire process seamless for medical organizations. With healthcare credentialing, real-time primary-sourced data can be centralized and automated. This promotes easier, quicker, more secure, and more accurate provider verification. Practices using medical credentialing platforms can experience shortened facility credentialing time by 70% while lowering the overall administrative time by more than 80% and cutting down the credentialing costs.
ii. Reduced years for organizations to verify claims histories
Earlier, it was common to request claims histories from as far back as when the applicant completed training till the present day. Now, most providers choose to look back between 6-10 years instead. Imagine a healthcare provider who completed a residency in 1980 in a high-risk specialty with a $5,000 nuisance settlement to close a case from 20 years ago. Implementing this change can help cut down process time, keeping you and your applicants happier throughout the process.
iii. Creating a navigator or concierge program to handle onboarding will gain popularity
Onboarding will trend rapidly in 2023, with almost 44% of medical staff offices responsible for the process. It also includes the creation of a navigator or a concierge program to manage all onboarding-specific tasks. This role would serve as the primary contact for the provider and guide them throughout the entire process. Though only 12% of surveyors will be heading in that direction, it will continue to expand and deliver value.
iv. Strict Profit margins
It has been predicted that hospital operating margins may continue to decrease in 2023, with hospitals operating on tight margins, increasing the cash flow and the ability to result in a maximum revenue cycle. This will drive digital technology and process innovation as healthcare leaders strive to improve business outcomes.
v.Home healthcare and medical credentialing
Private duty nursing, non-clinical care, companionship services will continue to gain popularity. As healthcare providers integrate homecare, healthcare leaders and managers will need to adopt advanced technology for medical credentialing.
The healthcare sector is becoming more and more patient-centric, which makes it all the more important for providers to stay up-to-date with their credentials. Provider credentialing can enable healthcare institutions to build trust among the patients and deliver patient-focused care. Healthcare leaders need to give importance to patient-centricity. They can begin with updated credentials, automated medical billing, and better practice management.
The COVID pandemic served posed trying times which also impacted the healthcare credentialing market. While there were job losses across the globe, the number of uninsured people did not increase. However, there have been fluctuations in the enrolment trends. For instance, Medicaid enrolment went up when employer-sponsored plans recorded declines. Enrolment in Medicaid and the Children’s Health Insurance Program reached 83.2 million members in June 2021.
10. Dos and Don’ts of medical credentialing
Integration of automated healthcare credentialing software may be associated with errors if not done correctly. Here we have provided a list of do’s and don’ts so that you can implement the technology with ease.
1. Begin Early
You can consider the average time frame as 3 to 6 months. Since the beginning of the year and August/September networks are usually slow, you may face delays in processing.
2. Carefully store all the documents
- Make sure that your CAQH is up to date
- Ensure that healthcare credentials, License and Malpractice are all up to date
- Update your CV with all information on the current practice
3. Know your State Regulations
- Each insurance provider offers different regulations
- Requirements may vary as per the States
4. Expect Additional Fees
Networks may charge you extra fees, so be prepared for that.
5. Find a Credentialing Coordinator
Whether you decide to outsource credentialing tasks or manage them in-house, it is important to assign a credentialing coordinator. This will help you to remain on top of the deadlines and stay ahead in the competition. A credential coordinator can send out timely reminders to help ensure that your healthcare credentialing does not expire. In this way, you can avoid denials of reimbursements.
6. Give time for the Credentialing Process to complete
While healthcare credentialing roughly takes about 90 days, it would be a good idea to give it around 150 days. Provider credentialing with payers must occur on their timeline, where each payer has its own healthcare credentialing timeline. Assume credentialing will require 150 days, so in case it happens sooner, you will be pleasantly surprised.
7. Remain Updated about the Coalition for Affordable Quality Healthcare’s Credentialing Program
The Coalition for Affordable Quality Healthcare (CAQH) uniform credentialing program is becoming popular among the payers. Clinicians who regularly update and attest their information with the CAQH are likely to have efficient healthcare credentialing and re-credentialing experiences. This makes it worth interfacing with CAQH.
8. Link a New Provider’s Start Date to Submission of Credentialing Forms
Many practices request credentialing paperwork as soon as an employment offer is made. Still, others link a new physician’s starting date to paperwork submission. You could make a new physician’s starting date no fewer than 120 days after you receive his or her credentialing information.
9. Create a Credentialing Process that lasts
Developing a healthcare credentialing workflow can be challenging, but it is needed for the long run. Your hospital workflow should maintain all the necessary forms and documents. This applies to events when you outsource the medical credentialing process. With a multi-physician practice, re-credentialing is always coming up, and a workflow to accommodate it can be beneficial.
10. Update All Physician Contact Information
Make sure that the credentialing coordinator maintains a complete and up-to-date record containing the contact information of every physician. Lack of direct contact can result in healthcare credentialing or re-credentialing issues taking a longer duration. The provider credentialing process also consists of multiple forms submissions that require clear communication.
11. Ensure All Physicians Understand What is Expected from Them
Every healthcare provider must be aware of his or her responsibilities in terms of healthcare credentialing or re-credentialing. When the offer of employment proceeds, it is crucial to clarify that you would need particular information, such as work and education history.
12. Organize Your Background Check Early On
Clinical practices must opt to perform their background checks on new physicians, such as verifying training, licensure, and employment history prior to making an employment offer. This can prevent hiring a clinician from facing issues with license and healthcare credentialing.
13. Be Well-Acquainted with Your State’s Regulations
Every state has its own laws for provider credentialing, and you may have different laws consisting of reciprocity agreements. If a doctor is credentialed with a payer in one state before moving to your practice, then the payer can streamline credentialing for the new job.
a. Don’t Assume that all is fine
- Rather than assuming all is ok, it is best to follow up after submitting something
- Conduct frequent follow-ups
- These will help to identify any mistakes by the insurance network
b. Don’t Wait till the last minute for tasks
Do not wait till the last moment to:
- Update documents
- Add providers to your plans
- Notify the insurance companies of changes like adding a new address
c. Don’t forget to Re-check
If you miss revalidating or re-credentialing, it can stop your payments.
d. Don’t Assume New Physicians can bill as Locum Tenens
When it comes to some payers, you can bill for a new physician whose credentialing isn’t complete by designating them as locum tenens, implying a fill-in clinician. However, all payers will not allow this to happen. So, it is advisable to get the physician fully credentialed to stop supporting normal billing. In case you cannot do so, contact the payers to understand their policy on locum tenens billing.
It is crucial to understand how physician credentialing works so that you can introduce a positive impact in terms of how smoothly a practice runs and the pace of cash flow. Problems with healthcare credentialing can cost you a lot and hamper productivity. Therefore, you need to learn the dos and don’ts to have an efficient medical credentialing process in place that remains up-to-date.
11. How OSP can help you build a healthcare credentialing software
OSP has the expertise, experience, and technical knowledge required to help you create a medical credentialing system that simplifies your challenges. Here, we have explained our strengths in detail.
Credentialing services refer to a smart system designed for healthcare providers to maintain their licenses and certificates. OSP can build software solutions for provider credentialing services to help you achieve updated credentialing and re-credentialing. Our team of experienced software developers can enable providers to deliver efficient physician credentialing services. With our custom-designed credentialing software solution, providers can experience seamless credentialing certification management in their medical credentialing services.
We understand the complexities involved in provider enrolment and credentialing services. With OSP’s software solutions, providers can obtain automated operations that will replace manual credentialing. OSP can enhance provider credentialing process flow and medical billing credentialing. Team OSP can automate the entire credentialing process and reduce costs. Our best credentialing services can help providers get credentialed and eliminate tedious manual operations in their credentialing process.
Verification of provider credentials is a time-consuming task, and errors can further delay the whole process. Healthcare credentialing includes data collection from physicians, developing the credentialing strategy, and so on. OSP can help you streamline the provider enrolment process through our unique software solutions. We can automate data verification and task management. Provider credentialing process can be simplified and managed effectively to ensure that physicians have up-to-date credentials. OSP can enable clinicians to complete healthcare credentialing in real-time and avoid redundancy.
Our provider credentialing solutions are interoperable across different systems and networks. OSP’s medical credentialing software can track and manage provider credentials effectively. Our cloud-based medical credentialing system can enable providers to share and access files with ease. The provider credentials can be stored on cloud-based networks that support data sharing without compromising security. OSP can help providers overcome the challenges of data management. We can integrate automation in healthcare credentialing systems to simplify healthcare data management and data access.
OSP can create a user-friendly interface for provider credentialing that smoothens the provider enrolment process. Our advanced insurance credentialing service can prevent errors and avoid delays, at the same time promoting cost management. We can ensure that the payer credentialing process runs efficiently and, at the same time, it is compliant with HIPAA regulations. Healthcare credentialing involves processes such as data gathering, credential tracking, and data management. A medical credentialing platform has a centralized system for addressing challenges of automation and task management. Our customized healthcare credentialing software can help you achieve these and meet regulatory standards like HIPAA and NCQA.
The healthcare industry went through a tough time with the transformation using digital health. Digital technology has simplified healthcare credentialing and managed the costs of transitioning towards accountable care. This involves the integration and automation of critical processes across the entire continuum of care. The complexities and pressures associated with COVID-19 and the evolving federal norms have put healthcare organizations under pressure like never before.
Automation in healthcare in the credentialing process could not have arrived at a more crucial time. It is capable of reducing complex credentialing workflows, managing revenue generation, and speeding up operational demands. Embracing this automation technology in healthcare credentialing will ensure optimization, efficiency, and agility and secure your health facilities’ position within a highly competitive landscape.
OSP can create healthcare credentialing and enrolment solutions. Our custom provider credentialing can help physicians start or join a new practice. We can enable healthcare providers to switch from one practice group to another. Team OSP has expert software developers who can allow you to enrol with new payers for healthcare credentialing. We can maintain your credentialing services in healthcare. Our healthcare credentialing process collects all the data and documents needed to fill applications from physicians. OSP’s custom-designed provider credentialing software can store the documents centrally on our secure document management systems.
We understand the top payers that receive claims from healthcare institutions and initiate contact with them. Team OSP can integrate payer-specific formats after a due audit. Our efficient provider credentialing system can help you perform a timely follow-up with payers to track the application status. OSP’s unique credentialing software can help you obtain the enrolment number from the payers and communicate the status of the application to the physicians. We can help you receive periodic updates of the document library for healthcare credentialing.
OSP is a trusted software development company that delivers bespoke solutions as per your business needs. Connect with us to hire the best talents in the industry to build enterprise-grade software.
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Written by Riken Shah linkedin
Riken's work motto is to help healthcare providers use technological advancements to make healthcare easily accessible to all stakeholders, from providers to patients. Under his leadership and guidance, OSP Labs has successfully developed over 600 customized software solutions for 200+ healthcare clients across continents.