1.800.360.0603

GE Healthcare Camden Group Insights Blog

5 Proven Tips to Improve Provider Credentialing

Posted by Matthew Smith on Aug 15, 2014 9:11:00 AM

Credentialing, Provider Credentialing, Outsourced Managed CareProvider credentialing is often thought of as a routine business office task. Everyone assumes it will get done but only a few people actually know how it happens. However, as hospitals and health systems employ more physicians, they are paying more attention to the function.

The concept of provider credentialing is relatively straightforward. A healthcare organization sends information about a physician’s or provider’s qualifications—work history, education, certifications, licensure, and so on—to a payer for review and verification. After thoroughly vetting the information, the payer confirms the provider and begins reimbursing him or her for services rendered. Every two years, the process repeats.

Note that credentialing is different from the more nuanced process of privileging, where an organization assesses physician competency and authorizes practitioners to provide specific services to patients. The focus of this article is on the physician credentialing effort.

Simple in Theory, Challenging in Practice

Executing a consistent and reliable credentialing program is not always easy. “The volume and variety of information payers need make this a detail-heavy job that can easily go off track,” says Beth Tanner, accountant at Cameron Memorial Community Hospital. “For example, Payer A may require original documentation and the physician’s signature in black pen, while Payer B may need slightly different documentation and no physician signature. If you send the wrong thing to a payer, they don’t automatically let you know. If you don’t follow up, you could be in a situation where the provider is ready to start and the payer has cancelled his application because of a missed detail.”

In many cases, healthcare organizations do not allocate full-time resources to the credentialing effort and, as a result, an already busy staff person is tasked with managing the process amidst other priorities.

If the person hiring a physician forgets to communicate with the person in charge of credentialing, it can further delay the already time-consuming task. “Credentialing can take between 30 and 120 days depending on the provider and payer,” says Tanner. “If you don’t find out about a physician starting until a few days before his or her first day, you already are behind the eight ball and you will be late.”

The Consequences of a Poor Process

In addition to the malpractice and regulatory risks, a weak credentialing effort can have serious financial ramifications for a hospital or physician practice that employs physicians. “If a physician is not credentialed before he or she starts to see patients, then the physician may not be reimbursed by the payer for his or her services depending on the patient’s out-of-network benefit,” says Sabrina Burnett, vice president of Health Directions, LLC. “If the physician has already started receiving a salary from the hospital, then the organization is paying money out without taking any in.”

There are also potential patient satisfaction impacts. “If a provider sees a patient before being credentialed, the patient may receive an estimate of benefits from the payer indicating the patient went to an out-of-network provider and needs to pay a higher copay, deductible, or the entire bill,” continues Burnett. “This can cause patient dissatisfaction and may even affect an individual’s decision to stay with a provider long term.”

5 Strategies for Improving Credentialing

While credentialing has many moving parts, there are a few key strategies for systemizing the process and supporting better accuracy and efficiency.

1. Develop policies and procedures. These should address the who, what, when, and where of commercial and government payer credentialing. For example, a policy should describe how staff obtain accurate credentialing information.

“Organizations may want to require providers to maintain a current profile in the not-for-profit Councils for Affordable Quality Healthcare (CAQH) database,” says Tanner. “This database houses most of the information needed for credentialing. If a physician keeps his or her profile up to date, then the credentialing department can access information from one central location, limiting the need to hunt down items from various sources.”

Organizations also should outline the credentialing steps for commercial versus government payers. Medicare has described its process on its website.

“Enrolling providers in Medicare and Medicaid is usually a little easier than the commercial credentialing process, but there are some unique nuances that providers should fully understand,” comments Tanner.

It can also be useful to outline payer follow-up times, says Burnett. “For instance, you may want to state that for all commercial payers, you will follow up at 30 days and then every 15 days after that.”

2. Create a centralized credentialing function. For organizations that hire a large number of physicians and/or have multiple sites, it can be beneficial to centralize the credentialing process.

“Having one department focusing on credentialing helps with efficiency and eliminates duplication of work,” says Burnett. “It can also enhance provider satisfaction. For instance, if a three-hospital system has separate credentialing departments with different people working on commercial payer and government payer credentialing in each department, then the provider could receive multiple phone calls asking for very similar information. Having a centralized department limits provider contact and prevents frustration. It also gives the provider one source for asking follow-up questions, heading off the possibility of miscommunication or information getting lost.”

3. Allocate sufficient staff. Even if centralizing is not a possibility, organizations should try to dedicate specific staff to the credentialing effort instead of lumping the job with other responsibilities.

“I am a staff accountant and in charge of commercial payer credentialing as one aspect of my job,” says Tanner. “Since we are a small hospital and don’t credential a lot of providers at one time, I have been able to manage the work. However, if we start hiring more physicians this may become difficult. In the ideal situation, you would have people dedicated to this work and some redundancy. It’s not always easy to step into a credentialing professional’s shoes because of all the details, so it is helpful if there is trained back up.”

When looking to hire an individual or individuals to spearhead physician credentialing, look for people who are organized, detailed-oriented, and proactive. “This job requires someone who is comfortable juggling a lot of details and is not afraid to follow up with payers,” says Tanner.

A number of hospitals and health systems choose to outsource credentialing. “Depending on your organization, this could be a good approach,” says Burnett. “You don’t have to recreate the wheel, and it can be seamless with the rest of the business office. An outside firm can also weather fluctuations in physician hiring, allowing you to scale up when the organization is bringing on a lot of new physicians and reduce the effort when hiring slows.”

4. Leverage technology. Some organizations choose to create their own technology tools to facilitate the credentialing process. “I rely on multiple spreadsheets to keep track of effective dates, provider status, and payer requirements,” says Tanner. “By having a cheat sheet for each commercial payer, I can manage the different requirements and make adjustments as things change.”

Others opt to use specific credentialing software. “A solution that is especially designed to support credentialing can trigger action through automated reminders and alerts, ensuring providers don’t fall through the cracks,” comments Burnett. “You can also pull up a provider record and see the status for all payers in one location.”

5. Build relationships with payers. While technology can enable an efficient process, healthcare organizations cannot ignore the human element when it comes to credentialing. “Strong relationships with payers are key,” says Burnett. “That way if there are problems or issues with a provider’s application, you can pick up the phone and resolve them in real time, instead of waiting for a letter or, even worse, receiving no communication at all.”

Good relationships can also allow an organization to be more proactive. “Having a strong rapport has been helpful on many levels,” comments Tanner. “First, the reps give me the heads up when things are changing so I know ahead of time instead of after I send all the information. Second, if we have a situation where we need to expedite approval, they can sometimes move the process along. In particular, if there is a hold up on their end, they can work to get to the bottom of it.”

A Little Work Goes a Long Way

While improving provider credentialing may not be a top priority for every organization, having a streamlined process can ensure timely reimbursement and prevent unnecessary delays that could impact revenue and patient satisfaction. Developing consistent policies, allocating the appropriate resources and technology, and building relationships can help your organization onboard physicians faster and smoother.

______________________________________

Originally published Tuesday, July 22, 2014 by HFMA. Kathleen B. Vega, author.

Topics: credentialing, Provider Credentialing, Managed Care, Outsourced Managed Care

Centralize Provider Credentialing to Create Staffing Efficiencies

Posted by Matthew Smith on Mar 19, 2013 4:59:00 PM

Credentialing AnalysisPhysician credentialing is a low-profile function within healthcare management. Credentialing is perceived as routine, and FTEs devoted to this work are seen as an overhead expense. But while credentialing plays a minor role in healthcare administration, poor execution can cause problems. Everyone is aware that credentialing lapses can expose a healthcare organization to malpractice suits and accreditation problems. More commonly, credentialing mistakes lead to financial losses on provider services. Even in organizations that avoid major problems, inefficient credentialing needlessly increases administrative costs. Worst of all, poor credentialing processes create friction with physicians.

The solution to all these problems is centralization of the credentialing function. Leading healthcare organizations have reduced costs and improved outcomes by creating a consolidated team to manage credentialing across the entire enterprise.

Problems with the Status Quo

Provider credentialing is straightforward but detail intensive. It includes applying for and obtaining network participation with payers (Federal and commercial) and securing hospital privileges. The basic workflow is cyclical: capture physician information (degrees, residency information, licenses, references, etc.), submit applications, and manage periodic renewals.

Credentialing staff must also coordinate several related items, including jurisprudence exams and specs tests. Specific requirements can vary by state. In most medical groups, the credentialing function is located in the billing department or the administrative office. Typically, credentialing work is a secondary responsibility for several staff members. Even when someone is hired specifically to handle credentialing, it often happens that he or she is gradually handed additional tasks that dilute the focus of the position.

Credentialing staff typically use a variety of “homegrown” methods and tools, including spreadsheets, personal checklists, and a variety of reminder systems. Many organizations have a long-tenured credentialing employee who does a good job using these tools. One problem with this type of system is dependence upon the expertise of one staff member. Without the credentialing point person on hand, the whole process comes to a standstill. Another problem is that makeshift tools do not scale well. Significant growth in credentialing volume or complexity can easily outstrip the capabilities of the system.

Diluted staff focus and poor tools can lead to problems with efficiency and accuracy. The biggest problem, however, is that they create a reactive environment. Work is driven by impending deadlines, not proactive planning. Physicians often bear the brunt—as when a physician has to spend two full weekends taking CME classes because he or she was informed at the last minute about an impending loss of hospital privileges.

Complicating the situation is the fact that in many larger organizations, credentialing responsibilities are distributed among several different departments and facility locations. As a result, physicians are approached by multiple individuals for the same information.

Growing Pressure

Recent developments in health care are exposing the weaknesses of traditional approaches to credentialing. As consolidation drives the formation of larger medical groups, administrative staffers are struggling to keep up with the demands of physician onboarding. Also, growth in physician employment by hospitals is rapidly expanding the volume of credentialing work handled by staffers who are comfortable with privileging work but are unfamiliar with the requirements and processes of payer credentialing.

The growing pressure on traditional credentialing systems is creating greater financial risk. If an organization fails to properly credential a physician with Medicare and other payers, the doctor cannot bill for services. ­is means lost revenue for the group (in the context of employment) and/or the provider.

Unfortunately, the margin of error recently became thinner. A 2009 change in Medicare regulations reduced the service backdating window from 27 months to only 30 days. Th­e problem is not just theoretical. In 2009 a practice management company was forced to pay more than $250,000 to compensate a client for lost revenue stemming from a credentialing lapse.

Centralized Credentialing

The key to addressing all these problems—inefficiency, service shortfalls, financial risk—is to recognize the limitations of traditional, fragmented approaches to credentialing, which do not take advantage of opportunities to standardize and streamline processes. ­They should be replaced by a strategy of consolidation: creating a professional, centralized unit that handles all credentialing, privileging, and related tasks. Healthcare organizations that have converted to centralized credentialing have realized several benefits in efficiency and outcomes:

  • Staffing cost reduction. In 2009 a national hospitalist group consolidated its credentialing function, reducing total credentialing staff from 20 to 10 and cutting total credentialing FTEs by approximately one-third.
  • Service improvement. Centralizing staff and processes leads to better service to physicians. Consolidation avoids duplicate requests to physicians for information, and working proactively helps eliminate deadline crises.
  • Revenue cycle optimization. In my experience, a well-designed credentialing unit can reduce credentialing-related billing problems to essentially zero.

Healthcare organizations can achieve all these benefits through the right mix of organization, staff skills, processes, and tools. Based on our company's (Health Directions) experience consulting with several provider organizations, we have found several factors are important to building a high-performing credentialing function. These factors include:

Manage Each Physician as a Single Account

As noted previously, when credentialing staff are dispersed throughout an organization, physicians receive poor service. In a typical scenario, a physician might be contacted by an employee responsible for government credentialing, another person responsible for PHO credentialing, plus privileging staffers from five separate hospitals. Each person needs basically the same information.

In contrast, centralized credentialing enables staff to treat each physician as a single, coordinated account. Team members identify all the information and documentation needed for an entire credentialing/ privileging panel and contact each physician once per year.

In larger credentialing teams, single-account management will be facilitated by choosing the right way to divide the work. There are two basic approaches:

  • Divide the work by function. For example, one team member will handle hospital privileging, another will manage credentialing with government payers, a third will be responsible for commercial HMOs, etc.
  • Assign accounts by specialty. Under this system, individual team members handle all the credentialing for physicians in designated specialties. One staffer might be responsible for cardiologists, urologists, and family practitioners; another would take care of physicians in neurology, nephrology, and gastroenterology; and so on.

Both systems can work, but the second approach enables greater individualized attention to physicians. Dividing the work by specialty allows credentialing team members to master specialty specific requirements. For example, the team member responsible for anesthesiology will develop an in-depth understanding of hospital sedation privileges. Under this system, each physician account is “owned” by one credentialing team member, providing further assurance that critical details do not slip through the cracks.

Emphasize Relationships

Credentialing is not just paperwork. It is a “high touch” discipline that relies on cooperation and input from multiple stakeholders. Effective credentialing teams focus on building strong individual relationships with payer representatives, government contacts, medical staff liaisons, and many others.

Personal relationships are often the key to resolving credentialing problems quickly. The ability to call a known contact (as opposed to the unknown person answering an 800 number) can mean the difference between overcoming a process snag in minutes rather than in days. A strong relationship can even head off a problem before it develops. Let’s say a health plan credentialing application is missing a minor piece of information. A payer representative who knows the credentialing team member is likely to call up and simply request the missing information. When there is no relationship, the entire application is likely to be returned as incomplete, causing a significant delay.

For this reason, developing a credentialing team should focus on fostering strong relationship-building skills. In addition, compensation packages should be designed to minimize turnover.

Maintain Positive Relationships with Physicians

Medical group leaders seeking new administrative efficiencies should not overlook the opportunity to streamline credentialing staff and processes. Centralized credentialing can also be an important element of physician relations. As the provider consolidation trend continues, leaders can expect more points of friction to develop between physicians and administration. A professional credentialing unit can help minimize avoidable problems and support positive working relations among all parties.

Provider Credentialing Analysis

Topics: outsourced managed care services, credentialing, Centralized Provider credentialing services, Physician credentialing

How Centralized Provider Credentialing Creates Staffing Efficiencies

Posted by Matthew Smith on Jul 27, 2012 1:46:00 PM

Provider CredentialingPhysician credentialing is a low-profile function within healthcare management. Credentialing is perceived as routine, and FTEs devoted to this work are seen as an overhead expense. But while credentialing plays a minor role in healthcare administration, poor execution can cause problems. Everyone is aware that credentialing lapses can expose a healthcare organization to malpractice suits and accreditation problems. More commonly, credentialing mistakes lead to financial losses on provider services. Even in organizations that avoid major problems, inefficient credentialing needlessly increases administrative costs. Worst of all, poor credentialing processes create friction with physicians.

The solution to all these problems is centralization of the credentialing function. Leading healthcare organizations have reduced costs and improved outcomes by creating a consolidated team to manage credentialing across the entire enterprise.

Problems with the Status Quo

Provider credentialing is straightforward but detail intensive. It includes applying for and obtaining network participation with payers (Federal and commercial) and securing hospital privileges. The basic workflow is cyclical: capture physician information (degrees, residency information, licenses, references, etc.), submit applications, and manage periodic renewals.

Credentialing staff must also coordinate several related items, including jurisprudence exams and specs tests. Specific requirements can vary by state. In most medical groups, the credentialing function is located in the billing department or the administrative office. Typically, credentialing work is a secondary responsibility for several staff members. Even when someone is hired specifically to handle credentialing, it often happens that he or she is gradually handed additional tasks that dilute the focus of the position.

Credentialing staff typically use a variety of “homegrown” methods and tools, including spreadsheets, personal checklists, and a variety of reminder systems. Many organizations have a long-tenured credentialing employee who does a good job using these tools. One problem with this type of system is dependence upon the expertise of one staff member. Without the credentialing point person on hand, the whole process comes to a standstill. Another problem is that makeshift tools do not scale well. Significant growth in credentialing volume or complexity can easily outstrip the capabilities of the system.

Diluted staff focus and poor tools can lead to problems with efficiency and accuracy. The biggest problem, however, is that they create a reactive environment. Work is driven by impending deadlines, not proactive planning. Physicians often bear the brunt—as when a physician has to spend two full weekends taking CME classes because he or she was informed at the last minute about an impending loss of hospital privileges.

Complicating the situation is the fact that in many larger organizations, credentialing responsibilities are distributed among several different departments and facility locations. As a result, physicians are approached by multiple individuals for the same information.

Growing Pressure

Recent developments in health care are exposing the weaknesses of traditional approaches to credentialing. As consolidation drives the formation of larger medical groups, administrative staffers are struggling to keep up with the demands of physician onboarding. Also, growth in physician employment by hospitals is rapidly expanding the volume of credentialing work handled by staffers who are comfortable with privileging work but are unfamiliar with the requirements and processes of payer credentialing.

The growing pressure on traditional credentialing systems is creating greater financial risk. If an organization fails to properly credential a physician with Medicare and other payers, the doctor cannot bill for services. ­is means lost revenue for the group (in the context of employment) and/or the provider.

Unfortunately, the margin of error recently became thinner. A 2009 change in Medicare regulations reduced the service backdating window from 27 months to only 30 days. Th­e problem is not just theoretical. In 2009 a practice management company was forced to pay more than $250,000 to compensate a client for lost revenue stemming from a credentialing lapse.

Centralized Credentialing

The key to addressing all these problems—inefficiency, service shortfalls, financial risk—is to recognize the limitations of traditional, fragmented approaches to credentialing, which do not take advantage of opportunities to standardize and streamline processes. ­They should be replaced by a strategy of consolidation: creating a professional, centralized unit that handles all credentialing, privileging, and related tasks. Healthcare organizations that have converted to centralized credentialing have realized several benefits in efficiency and outcomes:

  • Staffing cost reduction. In 2009 a national hospitalist group consolidated its credentialing function, reducing total credentialing staff from 20 to 10 and cutting total credentialing FTEs by approximately one-third.
  • Service improvement. Centralizing staff and processes leads to better service to physicians. Consolidation avoids duplicate requests to physicians for information, and working proactively helps eliminate deadline crises.
  • Revenue cycle optimization. In my experience, a well-designed credentialing unit can reduce credentialing-related billing problems to essentially zero.

Healthcare organizations can achieve all these benefits through the right mix of organization, staff skills, processes, and tools. Based on our company's (Health Directions) experience consulting with several provider organizations, we have found several factors are important to building a high-performing credentialing function. These factors include:

Manage Each Physician as a Single Account

As noted previously, when credentialing staff are dispersed throughout an organization, physicians receive poor service. In a typical scenario, a physician might be contacted by an employee responsible for government credentialing, another person responsible for PHO credentialing, plus privileging staffers from five separate hospitals. Each person needs basically the same information.

In contrast, centralized credentialing enables staff to treat each physician as a single, coordinated account. Team members identify all the information and documentation needed for an entire credentialing/ privileging panel and contact each physician once per year.

In larger credentialing teams, single-account management will be facilitated by choosing the right way to divide the work. There are two basic approaches:

  • Divide the work by function. For example, one team member will handle hospital privileging, another will manage credentialing with government payers, a third will be responsible for commercial HMOs, etc.
  • Assign accounts by specialty. Under this system, individual team members handle all the credentialing for physicians in designated specialties. One staffer might be responsible for cardiologists, urologists, and family practitioners; another would take care of physicians in neurology, nephrology, and gastroenterology; and so on.

Both systems can work, but the second approach enables greater individualized attention to physicians. Dividing the work by specialty allows credentialing team members to master specialty specific requirements. For example, the team member responsible for anesthesiology will develop an in-depth understanding of hospital sedation privileges. Under this system, each physician account is “owned” by one credentialing team member, providing further assurance that critical details do not slip through the cracks.

Emphasize Relationships

Credentialing is not just paperwork. It is a “high touch” discipline that relies on cooperation and input from multiple stakeholders. Effective credentialing teams focus on building strong individual relationships with payer representatives, government contacts, medical staff liaisons, and many others.

Personal relationships are often the key to resolving credentialing problems quickly. The ability to call a known contact (as opposed to the unknown person answering an 800 number) can mean the difference between overcoming a process snag in minutes rather than in days. A strong relationship can even head off a problem before it develops. Let’s say a health plan credentialing application is missing a minor piece of information. A payer representative who knows the credentialing team member is likely to call up and simply request the missing information. When there is no relationship, the entire application is likely to be returned as incomplete, causing a significant delay.

For this reason, developing a credentialing team should focus on fostering strong relationship-building skills. In addition, compensation packages should be designed to minimize turnover.

Maintain Positive Relationships with Physicians

Medical group leaders seeking new administrative efficiencies should not overlook the opportunity to streamline credentialing staff and processes. Centralized credentialing can also be an important element of physician relations. As the provider consolidation trend continues, leaders can expect more points of friction to develop between physicians and administration. A professional credentialing unit can help minimize avoidable problems and support positive working relations among all parties.

Topics: outsourced managed care services, credentialing, Centralized Provider credentialing services, Physician credentialing

3 Factors for Improving Your Provider Credentialing Services Program

Posted by Matthew Smith on Jun 6, 2012 5:00:00 PM

 

provider credentialing servicesWhile your provider credentialing services program might be a low-profile function within the overall healthcare management landscape, lapses in credentialing can open an organization up to malpractice suits or accreditation troubles. The solution is a centralized credentialing function resulting in reduced costs and improved outcomes via a consolidated team across the entire enterprise.

Recent developments in health care continue to expose the weaknesses in the traditional credentialing approach. Larger medical groups are built as the result of consolidation, and administrative staff struggle to keep up with the demands of physician onboarding. On top of that, growth in physician employment by hospitals is rapidly expanding the volume of credentialing work by staffers already stretched thin.

The solution lies in provider credentialing consolidation: a professional, centralized unit that handles all credentialing, privileging, and related tasks. The results are clear from succesful organizations who have installed a centralized approach: Measurable staffing cost reduction, service improvement, and revenue cycle optimization.

To achieve the right mix of organization, staff skills, processes, and tools, Health Directions has identified 3 factors necessary to improve provider credentialing services:

1. Create a Specialized Team

Specialization is the foundation for effective provider credentialing. This team should focus entirely on the the provider credentialing, privileging, and related functions and should not have side responsibilities (i.e. billing, administration, or recruiting).

2. Use Dedicated Credentialing Software

Effective credentialing teams use specialized software to coordinate credentialing information, automate functional expertise, manage workflows, and ensure continuity. Several vendor packages are available and have varying strengths and weaknesses but all offer benefits that homegrown systems cannot.

3. Take a Flexible Approach to Outside Resources

Many external credentialing services are available and can be integrated with in-house efforts for greater efficiency and cost-effectiveness. Outsourcing certain portions of credentialing also make sense. Some organizations may want to handle hospital privileging and government credentialing and would outsource commercial payer credentialing.

As the provider consolidation trend continues, a centralized--and sometimes outsourced--credentialing team will help avoid pitfalls and support positive working relations with all parties involved.

Topics: Provider credentialing services, outsourced managed care services, credentialing

Subscribe to Email Updates

Value Model, Health Analytics

Posts by Topic

Follow Me